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Mercyhurst University
CREATE Program Application
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This application is designed to help AIM Program staff understand your education, academic, and career goals, as well as your unique qualities. Individual initiative and academic capabilities are the basis of Mercyhurst's admissions policy. As a college that believes in an academically challenging environment, we want to ensure the CREATE at Mercyhurst is the right choice for you.
To apply for the CREATE summer program, you must be preparing to begin your senior year of high school, in your senior year, or a high school graduate.
After you have submitted this application, we must have received three letters of recommendation before we can review your application. (On this form, you'll provide the names and contact information for three people who will share insights about you via the recommendation form.)
First Name
Last Name
Birthdate
Birthdate
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1901
1900
Sex
Sex
Male
Female
Another
Email Address
Mailing Address
Mailing Address
Country
Street
City
Region
Postal Code
Primary Parent/Guardian Information
Parent/Guardian First Name
Parent/Guardian Last Name
Parent/Guardian Email
Parent/Guardian Phone
Secondary Parent/Guardian Information
Parent/Guardian First Name
Parent/Guardian Last Name
Parent/Guardian Email
Parent/Guardian Phone
Have you already submitted an application for the AIM program?
Have you already submitted an application for the AIM program?
Yes
No
Recommendations for CREATE Program
Recommenders you specify will be emailed links to our AIM Recommendation Form.
Recommender 1 First Name
Recommender 1 Last Name
Recommender 1 Email
Recommender 2 First Name
Recommender 2 Last Name
Recommender 2 Email
Recommender 3 First Name
Recommender 3 Last Name
Recommender 3 Email
Tell us why you want to be part of the AIM program. (200 words or less)
Please provide our team with information that highlights your strengths or makes you unique. (200 words or less)
Tell us about something you are interested in or passionate about. (500 words or less)
Supplemental Information
T-shirt Size
T-shirt Size
Small
Medium
Large
XL
XXL
Legal/Custody: With whom does the applicant live?
Legal/Custody: With whom does the applicant live?
Mother
Father
Both parents
Other
Please explain:
Are there any custody orders pertaining to the applicant?
Are there any custody orders pertaining to the applicant?
Yes
No
Please explain:
Psycho-Educational Summary
Providing a safe and beneficial pre-college and college experience is a primary goal of our program. Having relevant background information helps us know more about you as a student so we can better address your needs in the program and design experiences that will be more rewarding and effective. The information requested will be kept completely confidential.
High School
School District
Current Grade
Primary School Contact
Contact Phone
Contact Email
Type of High School Program
Type of High School Program
Public
Parochial
Private
Home School
Type of Program at the School (Select all that are appropriate.)
Regular classroom
Learning support
Autism support
Life skills
Emotional Support
Other
Please explain:
Special Services (Select all that are appropriate.)
Occupational Therapy
Physical Therapy
Speech Therapy
Does applicant have a 504 Plan or an I.E.P.?
Does applicant have a 504 Plan or an I.E.P.?
Yes
No
Please upload a copy of the 504 Plan or IEP.
Neuro-Psychological Information
Please upload a copy of the most recent Neuro-Psychological evaluation.
Date Completed
Date Completed
January
February
March
April
May
June
July
August
September
October
November
December
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Evaluator
Place Of Evaluation
Support Services
Has the applicant required a TSS or personal aide in the past 12 months?
Has the applicant required a TSS or personal aide in the past 12 months?
Yes
No
Please explain:
Does the applicant receive any of the following? (Select all that are appropriate.)
Group Therapy
Individual Therapy
Wraparound Service
Other
Name of Therapist/Agency
Therapist/Agency Phone
Therapist/Agency Email
Base Service Unit (if applicable)
Organization Name
Organization Address
Organization Address
Country
Street
City
Region
Postal Code
Name of Case Manager or Resource Coordinator
Case Manager or Resource Coordinator Phone
Case Manager or Resource Coordinator Fax
Behavioral Concerns
Please describe any behavioral concerns or comorbid diagnoses that you have that might impact your educational experience or transition to life on a college campus.
Student Conduct
Has the applicant ever been convicted of a misdemeanor, felony, or other crime?
Has the applicant ever been convicted of a misdemeanor, felony, or other crime?
Yes
No
Does the applicant have any pending criminal charges?
Does the applicant have any pending criminal charges?
Yes
No
You must submit the following information: accurate explanation, location of conviction pending criminal charges, suspension(s), expulsion, dates and court disposition. This statement must also include a grant of irrevocable authorization to the AIM Program for complete access to criminal records, if any. Complete information must be submitted at the time of application. A previous conviction, pending criminal charges, or other expulsion or dismissal does not automatically bar admission to the AIM Program, but does require review and evaluation. Any program student who has great difficulty in adjusting to this program or who proves to be a detriment to themselves or others may be discharged at the director's discretion.
Required Signatures
I certify that I have read and I understand all of the above information on this application. I certify that the information submitted is factually true and honestly presented.
Student Signature
Parent Signature
Submit
