Clemente Scholar Application Form

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The two-semester Clemente Course in the Humanities in Dorchester, MA will meet in person two nights a week, Mondays and Wednesdays, from 6:30-8:30 pm. The fall semester starts in mid-September and ends in mid-December. The spring semester starts mid-January and ends with graduation in late May. Students who successfully complete the requirements of the course are eligible to receive six free college credits from Bard College, transferable to any college or university.

If you are applying to start in January (Spring Semester), your term will run through the spring and into the following fall, and will conclude before the holidays in the following winter.

After you complete and submit this application, the Academic Director, Carter Hardy, will contact you to set up a phone or Zoom interview. More information is available on our website: https://www.codman.org/wellness-resource/adult-education/

If you have any questions, you can contact us at clementedot@gmail.com. We look forward to hearing from you!

Email *

First Name-: *

Last Name:
*

Date of Birth (we need this for awarding college credits) *

YYYY

Cell Phone *

Alternate Phone

Street Address
*

City
*

State *

Zip Code *

Gender *

Female

Male

Transgender

Non-Binary

Other/Prefer not to say

Preferred Pronouns

Race/Ethnicity *

Asian

Black/African

Caucasian

Hispanic/Latinx

Native American

Pacific Islander

Multi-racial

Other/Prefer not to say

Internet Access: how do you usually read emails and access Zoom? *

Phone

Computer

Public space (such as library)

Other:

Computer Access: *

I have access to a computer in my household that is three years old or less.

I do not have access to a computer in my household that is three years old or less.

Required

Employment status *

Employed full time

Employed part time

Self-employed

Not currently employed

Retired

Student

Other:

Education completed *

No GED or high school diploma

High school GED

High school graduate

Attended some college

Currently enrolled in college

Required

Marital status *

Single

Married

Separated

Divorced

Domestic Partner

Widowed

Other:

Number of children
*

Number of children under 18 living at home.
*

Approximate family income. *

Under $25,000

Between $25,000 and $50,000

Over $50,000

Other:

Please write a paragraph or two telling us what education means to you.
*

How did you hear about the Clemente program? Please check all that apply *

Word of mouth.

Saw a flier.

Saw online (Facebook or a group email).

Received an email about it (if possible, please tell us who sent the email).

Previously enrolled in Clemente.

Referred by a friend (if possible, please tell us who referred you).

Other:

Required

Details (if relevant to previous question)

Finally, what can we at Clemente do to help you and ensure that you do well in this course? (Being able to find a good balance dealing and succeeding in both school & work.) *

A copy of your responses will be emailed to the address you provided.

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