Request edit access
MAXIE COLLIER SCHOLARS PROGRAM          Online Application
College of Behavioral and Social Sciences 
2500 W. North Avenue, HHSB 339 
Baltimore, MD 21216
Sign in to Google to save your progress. Learn more
First Name, Last Name
CSU ID #
Declared Major
Cumulative GPA
Anticipated Graduation Date (Month & Year)
CSU Email Address
Personal Email Address
Mailing Address (including city, state, zip code)
Emergency Contact (Name & phone number)
Most Recent Work Experience:
Include Employer Name, Address, Position Held and Dates of Employment 
Volunteer Experience ( if applicable)
Organization, Volunteer Position, Dates, Duties:  
Why do you believe Coppin State University & the Maryland Department of Health agreed to name the Program in honor of Dr. Maxie T. Collier? (500 words max)
 *
Where do you see yourself in 5 years?  Please share your academic and professional goals? (500 words max):  
 *
Why do you want to participate in the Maxie Collier Scholars Program? (500 words max): 
 *
I understand this is a Scholars Program for students who are interested in pursuing a career in Behavioral Health. *
Required
I confirm I a resident of the State of Maryland.  Additional confirmation of your residency may be required.
FIELD EXPERIENCE/ INTERNSHIP: I understand I am expected to complete a field experience or internship in behavioral health prior to my Coppin State University graduation. Any exception to completing this requirement must be approved in advance by the Coordinator of the Program. Failure to satisfy this requirement will disqualify me as a Scholar and forfeit my entitlement to Maxie Collier Scholars Program funds. 
 *
Required
I understand I am to enroll in and successfully pass the HEED 105 Emerging Issues in Mental Health and Well Being course at Coppin State University prior to graduation. 
 *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms