SIMON’S ROCK COLLEGE OF BARD EMERGENCY ADMISSION PROGRAM

Office of Admission Phone: 800-235-7186

84 Alford Road Fax: 413-528-7334
Great Barrington, MA 01230 admit@simons-rock.edu

Simon’s Rock College of Bard is offering an emergency admission program for eleventh and twelfth grade students
affected by Hurricane Katrina.

Admitted students will be permitted to enroll on a semester-by-semester basis for the remainder of this academic year.
Interested students should submit the emergency application as soon as possible and applications will be reviewed
immediately. Financial assistance for tuition, room, board, and transportation costs is available and will be awarded on a
case-by-case basis. Students will receive support in adjusting to campus life and in catching up on missed coursework.

Simon's Rock College of Bard is the only four-year college of the liberal arts and sciences specifically designed to provide
bright, highly motivated students with the opportunity to begin college in a residential environment after the tenth or
eleventh grade. Students who successfully complete the requirements receive the Associate of Arts (A.A.) degree after
two years of study, and the Bachelor of Arts (B.A.) degree after four.

PERSONAL INFORMATION
Legal Name
Enter name exactly as it appears on birth certificate, passport, or other official documents.
Usually called Birth date / / Gender
Month Day Year
Current Address
Number and Street Apt. No.

City/Town State/Province Country Zip or Postal Code

Phone Fax
Cell phone Email

Citizenship
… US citizen … Dual US citizen; please specify other country of citizenship
… US Permanent Resident visa; citizen of Alien Registration Number
… Other citizenship
Country(ies) Visa type
If you are not a US citizen and live in the US, how long have you been in the country?

The following information is optional:

Please check all that apply:
… African American, Black … Mexican American, Chicano/a
… American Indian, Alaska Native (tribal affiliation enrolled ) … Native Hawaiian, Pacific
Islander
… Asian American (country/ies of family’s origin ) … Puerto Rican
… Asian, including Indian subcontinent (country/ies ) … White, Caucasian
… Hispanic, Latino/a (country/ies ) … Other (specify ))

First language if other than English Language(s) spoken at home

Place of Birth
City/Town State/Province Country

Social Security Number (if any)

FAMILY INFORMATION
Parent/Guardian 1 Parent/Guardian 2
Name Name
Last First Middle Last First Middle

Relationship to you Gender Relationship to you Gender

Living? … yes … no If no, date deceased Living? … yes … no If no, date deceased
Home address if different from yours Home address if different from yours

Home phone Home phone

Cell phone Cell phone
Fax Fax
Email Email
Parents’/Guardians’ marital status: … married … separated … divorced … never married … widowed
With whom do you make your permanent home? … Parent/Guardian 1 …Parent/Guardian 2 … Both
… Other relation/friend; please specify:
If your parents/guardians do not live at the same address, should college correspondence also be sent to the
parent/guardian with whom you do not legally reside? … yes … no
If yes, how should it be addressed?

Siblings
Name Age Indicate current grade or college attended

ACADEMIC INFORMATION
School you attend now
(or attended most recently) Dates attended

Current grade Secondary school graduation year

.
School Address
Number and Street .

City/Town State/Province Country Zip or Postal Code

Type of school: … public … private … parochial … home school

Guidance counselor’s name

Please include copies of any available high school grade reports or transcripts. If no reports or transcripts are available,
submit a chronological summary of courses taken in high school, noting course titles, levels (AP, IB, honors,), credit
value, and grades.

Please indicate below the title, level (AP, IB, honors, etc.) and credit value of all courses you are taking in the current
school year.
First Semester/Trimester Second Semester/Trimester Third Timester

List all other schools you have attended since the ninth grade beginning with the most recent. Include colleges or
universities at which you have taken courses for credit. Attach additional sheets if necessary.
Name of school Location Dates attended

Have you been out of school for more than one month (excluding summers and other official school vacations) since the
seventh grade? … yes … no
If yes, please explain on a separate piece of paper why and what you did during this time.

Have you been suspended, expelled, or required to withdraw from any of the schools you attended? … yes … no
If yes, please explain on a separate piece of paper.

ADDITIONAL INFORMATION
Standardized Test Scores
If you have taken the SAT, ACT, PSAT, or PLAN, please indicate below the date on which you took the test and the
scores you received.

Test taken Date taken/to be taken Scores (if taken)

Test taken Date taken/to be taken Scores (if taken)

Interview
An interview is required as part of the application. Interviews can be conducted by phone. Please indicate your plans
below.
… I have had an interview.
Name of interviewer Date
… I will call to schedule an interview.
… I plan to visit campus and be interviewed at that time.
Please indicate date of campus visit.
Essay
If possible, please submit an essay on one of the following topics or a previous school writing assignment or an essay on a
topic of your choice or any other sample of your writing.

1. Describe an idea, learning experience, creative process, literary work, or intellectual exercise you have
encountered during you’re the last two years and discuss how it has affected your thinking.
2. Discuss some issue of personal, local, national, or international concern and its importance to you.
3. Indicate a person who has had a significant influence on your, and describe that influence.

Student and Parent/Guardian Signatures

Simon’s Rock is academic community in which students are expected to be active and engaged learners, while
demonstrating honesty and integrity, and taking responsibility for their actions. By signing this form, the applicant and
parent attest that all information contained in this application is complete, factually accurate, and honestly presented. The
applicant agrees to contact the Office of Admission should any information contained herein change once the application
is submitted.

Applicant Signature Date

Parent/Guardian Signature Date