BASE Program Student Application

Please complete this form as thoroughly and honestly as possible.

Step 1 of 3

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General Information

Name(Required)

First Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Mobile phone(Required)

Email(Required)

Have you been accepted as a student at BC?(Required)

yes

What semester are you planning to begin at Bridgewater?(Required)

Do you plan to live on campus?(Required)

yes

Why did you choose to attend BC and what do you hope to gain from your college experience?(Required)

Why do you want to be a part of the BASE Program and what do you hope to gain from participating in this program?(Required)

How did you hear about the BASE Program?(Required)

High School Information

Name of High School(Required)

Graduation Date(Required)

Final GPA(Required)

Did you receive high school accommodations?(Required)

yes

If yes, what accommodations did you receive?(Required)

What accommodations were most helpful for you?(Required)

In the space below, please list the activities in which you participated during high school, how many years you were involved, and any leadership positions that you had.(Required)

click the + sign to add additional activities

High School Activities (include clubs, organizations, honor societies, athletics, etc

How many years did you participate in this activity?

What leadership roles, if any, did you hold (captain, section leader, officer, manager)?

Previous College Information

(please go to the next section if you have not attended college)

Name of College

City

State

Dates of attendance

month/year

Major/Program of Study

Number of credits completed

GPA

Did you receive college accommodations?

yes

If yes, what accommodations did you receive?

What accommodations were most helpful for you?

Personal Experiences

Have you participated in volunteer work?(Required)

yes

If yes, where did you volunteer? What type of work did you do?

Have you had a paying job?(Required)

yes

If yes, where did you work? What type of work did you do? How long were you employed?

Have you been away overnight without your parents or guardians?(Required)

yes

If yes, when and how long were you away?

Do you have a driver’s license?(Required)

yes

If yes, when did you earn it? How often do you drive?

Friendships and Free Time

Do you have friends that you see outside of school activities?(Required)

yes

If yes, how many friends and what type of activities do you do together?

What do you like to do for fun?(Required)

Do you do some of these activities with other people?(Required)

yes

If yes, with whom do you do these activities (friends, siblings, parents, etc.)?

What situations do you find stressful or frustrating? Check all that apply(Required)

Communicating with others

Working in groups

Getting feedback /taking criticism

Participating in social events

Not getting enough sleep

Getting work done on time

Loud noises

Lighting

Organizing school work

Crowds

Unclear directions

Planning transportation

Adjusting to changes in routine

Meeting new people

Being late

Things is in order/orderly

Parental involvement

Advocating for needs

What strategies do you use to calm yourself down in stressful or frustrating situations?(Required)

Medical Information

What is your diagnosed disability(ies)?(Required)

At what age were you diagnosed?(Required)

Are you currently working with a therapist (behavior, speech, etc.) and/or with a mental health provider?(Required)

yes

If yes, in what type of therapy are you currently involved?

What arrangements have you made to continue your therapy while attending BC?

Do you take daily medication?(Required)

yes

If yes, are you able to take it without reminders from other adults?

Most of the time

Occasionally

Rarely

Never

Disability-Related Information

How does your disability impact you in these four areas…

Academically(Required)

Socially(Required)

Behaviorally(Required)

In Daily Living(Required)

Consent(Required)

I agree to the BASE Program Agreement and Disclosure Statement

I understand that acceptance to Bridgewater College does not guarantee a spot in the BASE Program.

I understand that the BASE Program is not a counseling or therapeutic program. Students who require on-going counseling or therapeutic services will be referred to off-campus providers in accordance with university guidelines. Off-campus services are at the student’s expense.

I understand that the BASE Program does not offer specialized or monitored housing. Students living on-campus are expected to live independently in a residence hall setting.

I understand that if accepted into the BASE Program there will be costs incurred by me. Inability to pay may result in a hold on the student’s BC account or removal from the BASE Program.

I understand that the BASE Program is comprised of group and one-on-one meetings focused on social, academic, and employability skills. I agree to participate in the BASE Program and activities. I understand that no fees will be refunded if I choose not to participate.

I understand that regardless of the admission to and participating in support programs and/or services, that a strong academic record, even combined with comprehensive supports, does not guarantee college success or professional employment.

I understand that my application for the BASE program will not be reviewed until the student is accepted to BC.

BASE Program