Application for the SPRINGFIELD CLEMENTE COURSE in the HUMANITIES, 2022-2023

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Welcome! Thank you for considering the Clemente Course to further your education. Please fill out this application to the best of your ability. If you have questions, please contact Brenda Hill, the Clemente Course Site Coordinator, at TheClementeCourseSpringfield@gmail.com.
Be sure to complete the personal statement in the space provided or email your personal statement to the address above.

*Please note, this course will be offered remotely via Zoom for the 2022-2023 academic year, but there will be in-person gatherings throughout the year.

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Personal Information

First Name *

Last Name *

Email Address *

Date of Birth *

YYYY

Gender *

Female

Male

Nonbinary

Other:

Primary phone number *

Home address *

City *

Zip code *

Mailing Address, if different

Emergency Contact Name and Phone Number

Ethnic or Racial Heritage *

First Language *

Are you fully vaccinated against COVID-19? (your response will not impact acceptance. This information will be used to determine in-person gatherings). *

Yes

I plan to be fully vaccinated by September 2022

Education

Are you currently in school?

Yes

Clear selection

If so, where?

Did you graduate from high school? If so, when and name of high school

Are you a GED/HiSET recipient? If so, date of completion/expected completion

YYYY

Have you ever attended college? If so, where and years enrolled

Have you earned college credits? If so, how many?

Why did you leave college?

Family

Marital Status *

Single

Married

Separated

Divorced

Widowed

Do you have children? If so, what are their ages? Do they live with you?

What is your annual household income before taxes? *

under $1000

$1001-$5000

$5001-$10,000

$10,001-$15,000

$15,001-$20,000

$20,001-$25,00

$25,001-$30,000

Over $30,000

Work

Skills/Occupation

Employment Status

Full time

Part time

Unemployed

Internship

Volunteer

Clear selection

Are you currently in a training program? If so, specify

Support

For in person classes, will you need childcare? *

Yes

Maybe

For in person classes, will you need transportation assistance? *

Yes

Maybe

For remote (online) classes, you will need access to some type of computer or tablet with a camera and microphone and a reliable internet connection. If you are accepted into the course but don't have the equipment and/or internet access necessary to participate in the online sessions, Mass Humanities and Clemente Springfield will work with you to secure what you need. Need will NOT impact acceptance into the course. *

I have access to a computer, laptop, or tablet with a camera and microphone

I don't have access to a computer or tablet with camera and microphone

Internet Access *

I have access to an internet connection that is good enough to stream video.

I don't have access to my own internet subscription/My internet is unreliable

Personal Statement

Please respond to these questions in as much detail as possible:

What do you hope to learn or achieve by returning to school and taking college-level courses? *

What will you need to do to accomplish these goals? Discuss the challenges you expect to face. *

Describe your plans for the future, and anything else you would like to share with us. *

Your application will not be complete until you click on the "SUBMIT" button below.

*The Clemente Course and Bard College do not discriminate in education, employment, admission, or services on the basis of sex, sexual orientation, race, color, religion, national origin, or ability.

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