Phone

(925) 776 -1133

Office Hours

Mon - Fri: 9AM - 5PM

First Name (required)

Last Name (required)

Email address (required)

Date of Birth (required)

Phone number (required)

What city do you live in (required)

Where do you plan to go to school this fall (required)

Help us get to know you. What do you do for fun? What challenges are you facing, if any? What goals do you have for the future? Tell us as little or as much as you feel comfortable with. (required)

Why do you want to join the Road Map to College program? (required)

What is your ideal job after you finish school? (required)

Will you have a high school diploma before July 2018? (required)
Is this your first time going to college? (required)
Please check all that apply below. Please be honest and know that we are here to help you. Answering these questions will help us understand what challenges you may be facing, if any. We focus on providing additional support to individuals facing any of the obstacles below. (required)
Have a disability or had an IEP/504 plan in high school.
Pregnant or parenting.
Sometimes need to skip meals to make ends meet.
Current foster youth or have been in the foster care system before.
Have been convicted of a misdemeanor, felony, or currently have unresolved legal issues.
Have been terminated from a job.
Have a history of substance abuse.
Transportation to school or work is a challenge.
Currently dealing with or have dealt with domestic violence.
Temporarily living with a friend, in your car, or not sure where you are going to live long-term.
I am a member of a under-represented group in higher edutype='checkbox' cation.
Past trauma or significant emotional distress.
Lacking work experience or skills to reach employment goals.
None of these apply to me.

How did you hear about us? (required)
Opportunity Junction website
College To Road Map website
Friend or family member
My high school counselor or teacher
Los Medanos College staff member
Bay Area Community Resources (BACR)
Independent Living Skills Program (ILSP)
Uplift Family Services
Other

Other (Enter if you choose "Other" above)