Groups Program
2018 Application for Admissions

All blanks MUST be completed

Remember this is a college application please use correct punctuation and capitalization.


  1. Student's First Name:
    Student's Middle Name:
    Student's Last Name:

  2. Ethnicity:

  3. Date of Birth: (MM/DD/YYYY)

  4. Birthplace

  5. Are you a resident of the State of Indiana?

  6. Are you a U.S. Citizen? - If 'No', please email or fax a copy of your permanent resident card (green card) to or 812-856-5235

  7. Contact Phone Number: in this format xxx-xxx-xxxx

  8. Student's Email Address:
  9. Note: Be sure to check this email address often. Email is considered official communication at IU. Please email if your email address changes.
  10. Are you a ward of the court?

  11. Are you homeless?

  12. Do you have any relatives who have participated in the Groups Program?
    If Yes, Please List:
    Name: Groups Year Relationship
    Name: Groups Year Relationship
    Name: Groups Year Relationship

  13. Have you worked anywhere?
    If Yes, Where?

  14. Is English your first language?

  15. T-Shirt Size: 2XL


  17. Who does the student live with?
    Explain if Other

  18. Parent(s), Legal Guardian(s) or Adopted Parent(s) full names:

  19. Are your Parent(s), Legal Guardian(s) or Adopted Parent(s) residents of the State of Indiana?

  20. List an email address for a Parent, Legal Guardian, or Adopted Parent:

  21. Has your biological or adopted mother earned a four-year bachelors degree?

  22. Has your biological or adopted father earned a four-year bachelors degree?

  23. How many people live in your household?

  24. What was the annual income of your Parent(s), Legal Guardian(s) or Adopted Parent(s) last year? $
    (You may be asked to provide copies of tax documents for verification)


  26. Name of your High School:

  27. Name of your Recommender:
    Note: This must be the high school counselor or community member that gave you the information on applying to the program. If the person listed is not a registered recommender your application will be rejected.

  28. Recommender's Email address:

  29. Are you a 21st Century Scholar?

  30. Have you taken the SAT or ACT?

  31. List any extracurricular or volunteer activities:

  32. List any AP/Dual Credit/IB courses that you have already taken or will take during your senior year. Click here for more informaiton.
      Course Name Type College/University name if Applicable (Ex. Ivy Tech, Vincennes, IU, etc.) Course number if not IU (Ex. ENGL100, MA14300, etc.)


    This information is for providing services only and will not affect your acceptance to the program

  34. Do you have any documented disabilities?
    If yes, what is the disability?

  35. Have you had any significant illness in the past five years?
    If yes, please explain:

  36. Are you currently on any prescription medication?
    If yes, please explain:


Applicants must provide answers to both questions below. Each answer should be between 50-200 words and only ONE paragraph long. Do not add returns in your response. We suggest that you type out your answers in a word processing program, save it, and then copy and paste it into the online form.

  1. Discuss how you have persevered through an obstacle or adversity in your personal and/or academic life.

  2. Describe a long-term goal you have set for yourself and how you plan to accomplish it.

Please make sure you have read and understand the "Groups Scholars Program Partnership Agreement." By typing your name and date in the boxes below you agree to the following statement.

"I understand and agree that if I fail to abide by the conditions identified in the "Groups Scholars Program Partnership Agreement," I may be dismissed from the Groups Scholars Program, and that the Groups Grant I have been awarded, or that I might have been eligible to receive, will be cancelled."

Student's Name:

Today's Date: MM/DD/YYYY