Home › Life at Bridgewater › Student Resources › Academic Advising and Support › BASE Program › BASE Program Student Application BASE Program Student Application Please complete this form as thoroughly and honestly as possible. Step 1 of 3 33% General InformationName(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 no What semester are you planning to begin at Bridgewater?(Required) Do you plan to live on campus?(Required) yes no 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 InformationName of High School(Required) Graduation Date(Required) Final GPA(Required)Did you receive high school accommodations?(Required) yes no 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 activitiesHigh School Activities (include clubs, organizations, honor societies, athletics, etcHow many years did you participate in this activity?What leadership roles, if any, did you hold (captain, section leader, officer, manager)? Add RemovePrevious College Information(please go to the next section if you have not attended college)Name of College City State Dates of attendance month/yearMajor/Program of Study Number of credits completedGPADid you receive college accommodations? yes no If yes, what accommodations did you receive?What accommodations were most helpful for you? Personal ExperiencesHave you participated in volunteer work?(Required) yes no If yes, where did you volunteer? What type of work did you do?Have you had a paying job?(Required) yes no 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 no If yes, when and how long were you away?Do you have a driver’s license?(Required) yes no If yes, when did you earn it? How often do you drive?Friendships and Free TimeDo you have friends that you see outside of school activities?(Required) yes no 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 no 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 InformationWhat 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 no 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 no If yes, are you able to take it without reminders from other adults? Most of the time Occasionally Rarely Never Disability-Related InformationHow 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 StatementI 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.
