Fall 2015 Enrollment Application
Fall 2015 Enrollment Application Student Name: ____________________________________ Date Submitted: _____________ Current School: ____________________________________ Current Grade: ______________ Submit Application to: Allyson Lam, Operations Manager Due Date: 3/27/2015 Checklist of items that must be returned to College Track to receive invitation to an interview: ! Completed Student and Parent Information (Pages 2-5) ! Signed Release of Confidential Information (Page 6) ! Student Responses to essay prompt and other questions (Page 7) ! Two letters of recommendation, one each from a teacher and a counselor (Pages 8-11) (A third optional letter may be submitted from any non-related adult; Pages 12-13) ! A copy of your school transcript ! A copy of last year’s ELA and MATH CST scores (If you are a high school student and also have PSAT & CAHSEE scores, please also submit these.) To ensure that your complete application is received, we recommend keeping a copy of all submitted files. College Track 117 Broadway Oakland, CA 94607 Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program. Oakland Fund for Children and Youth College Track is looking for committed students who are motivated to obtain a college education and are ready for the rigorous structure and support that we provide. What is College Track? College Track is an after-school college completion program that helps students who have the motivation but lack the resources and support to obtain a college education. We help our students succeed in getting through high school, into college and to college graduation. We provide the tools and opportunities our students need to realize their dreams: academic support, extracurricular activities, community service, internships, and assistance in all aspects of the college application process. How does College Track help students get into college? College Track’s approach is intensive, comprehensive, and personalized so that we can best meet the needs of all of our students. College Track students are expected to participate in each of our four programs: • • • • Academic Affairs ensures that our students are both eligible and competitive for college admissions through academic remediation, tutoring, and counseling Student Life provides opportunities to create well-rounded, active student leaders through enrichment and service learning College Affairs exposes students to colleges and universities through presentations from representatives and visits to college campuses in and out of state. It assists students with financial preparation and application completion College Success provides support and guidance to students once they enroll in college When does it start and what is a typical day like? At the beginning of each semester, students attend an orientation and create their weekly College Track schedule, signing up for weekly workshops and tutoring sessions. Students will schedule to come in at least 2-3 times per week, on weekdays between 4pm and 7pm. During that time, they participate in one-on-one or small group tutoring depending on need and attend workshops or study groups aimed at enhancing academic performance. In addition, students take an enrichment course such as yoga, photography, cooking, poetry, or leadership. Students participate in advisory classes where they learn about colleges, scholarships, and how to complete their applications. Students may use the computer lab for academic purposes. Who may apply to College Track? We can support students best when we have allies at our students’ schools who are committed to working with us to ensure our students’ success. That’s why, as of March 2014, all students who will graduate from high school in 2018 or later must attend one of our target schools to receive admission to College Track: Coliseum College Prep Academy - Envision Academy for Arts & Technology – Fremont High School – Life Academy - Lighthouse Community Charter High School – McClymonds High School - Metwest High School – Oakland High School – Oakland Technical High School – Oakland Unity High School - Skyline High School High Schools - To inquire about becoming one of College Track’s target schools, please contact College Track at 510.350.4432. Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program. 1 Section 1: Student Information All information provided in this section is to be completed by the student applying to College Track. We will use this information to contact you about an interview so please ensure all information is clearly written and accurate. A. Personal Information First Name M.I. Student Email Address Last Name Gender ! Male ! Female Home Phone Birthdate (mm/dd/yyyy) ( Home Street Address Student Cell Phone ( City State Country of Birth ) ! U.S. Citizen ! Permanent Resident ! Neither ZIP Code Ethnic Background (Check all that apply) ! African-American ! Asian-American ! White / Caucasian ! Latino / Chicano ) What language(s) do you speak at home? ! Pacific Islander ! Native American ! Other: Are there any special accommodations you will need? If yes, please specify: __________________ Are you an orphan/ward of the court? ! Yes ! No B. Academic Information School Name* Current Grade School District Student’s State ID # (10-digit number on transcript) Cumulative GPA (6 - 8 or 9 - 12 ) th th th th *Please remember that all students who will graduate high school in 2018 or later must attend one of College Track’s target high schools to be admitted. See Page 1 for complete list of target schools. th Please attach a copy of your current school transcript. If you are in 8 grade, please also attach a copy of th your 7 grade CST scores. If you are a high school student who has taken CAHSEE, please provide a copy of your results. Your school counselor can help you find these important documents. Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program. 2 Section 2: Parent Information All information provided in this section is to be completed by the parent or guardian of the student applying to College Track. We will use this information to contact you about your child’s involvement in College Track. Please ensure all information is clearly written and accurate. A. Parent/Guardian Information Who does the student live with? ! Both parents/guardians ! Parent/Guardian #1 only ! Parent/Guardian #2 only Which parent/guardian is the primary contact? ! Both parents ! Parent/Guardian #1 only ! Parent/Guardian #2 only [OPTIONAL, response can be in any language] Please share 1-2 sentence(s) explaining why you want your child to be a part of College Track: Counting all salaries and earnings of people in your household, what is the total annual yearly income? ___________________________ Do not leave blank. Number of people in student’s household: ___________ I. Parent/Guardian #1 Information: First Name Email Address M.I. Last Name Relation to student: (e.g. mother, father, grandmother) _________________________ Education Level ! Did not start or finish high school ! High school degree ! Vocational school degree ! Some college (currently enrolled) ! Some college (not currently enrolled) ! 2-year college degree ! 4-year college degree ! Graduate degree Languages spoken: ! English - fluent ! English – basic ! Spanish ! Cantonese ! Other: ______________________ Daytime phone ( ) Cell Phone ( ) Employment: ! Full time occupation: ___________________ ! Not working In what country did you earn your highest degree? ! Part time occupation: ___________________ ! Disabled _______________________________ ! Other (please specify: __________________) Are you willing to volunteer time to support College Track activities? If so, please indicate all that apply: ! No, I am unable to volunteer ! Translation support ! Drive carpool of students to/from College Track ! Facilitate a workshop for parents ! Join a Parent Engagement Committee ! Bring snacks for students Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program. 3 II. Parent/Guardian #2 Information First Name M.I. Last Name Email Address Relation to student: Education Level ! Did not start or finish high school ! High school degree ! Vocational school degree ! Some college (currently enrolled) ! Some college (not currently enrolled) ! 2-year college degree ! 4-year college degree ! Graduate degree Daytime phone Languages spoken: ! English - fluent ! English – basic ! Spanish ! Cantonese ! Other: __________________________ ( ) Cell Phone ( ) Employment: ! Full time occupation: ___________________ ! Not working In what country did you earn your highest degree? ! Part time occupation: ___________________ ! Disabled _______________________________ ! Other (please specify: __________________) Are you willing to volunteer time to support College Track activities? If so, please indicate all that apply: ! No, I am unable to volunteer ! Translation support ! Drive carpool of students to/from College Track ! Facilitate a workshop for parents ! Join a Parent Engagement Committee ! Bring snacks for students Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program. 4 B. Healthcare Provider Information Healthcare Provider Does student have a primary care physician? ! Yes ! No Policy Number Phone ( Street Address Name of physician ) City State ZIP Code C. Emergency Information Give the name, address, and phone number of an adult who does not live with you but can be contacted in the event of an emergency. You must list at least one telephone number. Name Relationship to student Home Phone Cell Phone ( ( ) Street Address City ) State ZIP Code Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program. 5 Release of Confidential Information to Authorized Persons/Organizations Student Name* (Print): ___________________________________________________________ Student’s Date of Birth: ______________________________________________ Month Day Year Middle School: ______________________________ High School: ___________________________________ Expected High School Graduation Year: ______________________ Student’s School ID Number: _________________ Student’s State ID Number (CSIS #): _________________ Parent/Guardian Signature: _________________________________________________________________ *As shown on birth certificate (legal name). This can be found on student’s high school transcript. I hereby give permission for my child to participate in the activities of College Track. I have read the information about College Track and I am in support of my child’s participation. I will allow College Track to transport my child to and from College Track sponsored activities and their office, located at College Track Oakland 117 Broadway Oakland, CA 94607. II. I hereby grant College Track and its legal representatives and assigns, the irrevocable and unrestricted right to use and publish my child’s first name and initial to last name and all image and personality rights, including film, photograph, tape or video reproduction (together, “Materials”) in which my child may be included, for editorial, trade, advertising, website marketing and any other purpose and in any manner and medium (now existing or hereafter developed); to alter the same without restriction; and to copyright the same. I hereby release College Track and its legal representatives and assigns from all claims and liability relating to said Materials. INITIAL HERE__________ Even if my student is not accepted into the College Track program, III. I hereby authorize College Track to access data from the District as well as have access to and make copies of my child’s high school records (grades, test scores, attendance, enrollment) through the completion of high school and into post-secondary education. IV. I further authorize College Track to request, share and use all information held by College Track and its partners relating to me, with all higher education institutions and program partners for the purposes of enhancing my chances of graduating from college. This includes, but is not limited to, personal information (such as my name, mailing address, email address and date of birth), high school and college academic information (such as my high school courses, grades, test scores, college transcripts), financial information (such as any scholarships, financial aid and grants awarded to me), my recorded image and voice, and my applications, admissions, enrollment, attendance and academic status at higher education institutions (together, “My Information”). V. College Track monitors the progress of applicants and participants to better evaluate the effectiveness of its high school and college program in light of its charitable mission. As part of the monitoring process, College Track may share “My Information” with researchers and funders. I understand that College Track will take appropriate steps designed to secure and protect this information, to keep it confidential, and to prevent others from connecting it to me. To the extent possible, except as set forth in this form, any information that could identify me will be removed or changed before such information is shared with other researchers, organizations, or institutions and before any research results are made public in an aggregated form. Any waiver, modification or amendment of this form will be effective only if acknowledged and agreed to by College Track. Further, I understand that College Track will maintain a record of this form, that I am entitled to request and receive a copy, and that I may wish to make a copy of this form for my own records. This form will be governed by and construed in accordance with the laws of the State of California. College Track is a California Public Benefit organization (501(c)3). Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program. 6 Section 3: Student Questions A. Personal Statement Choose one of the five following questions and answer it on a separate sheet of paper, either typed or neatly handwritten. Provide a minimum of three paragraphs. 1) Describe a time you failed. What happened and how did you respond? 2) Identify a specific community you are a part of (e.g. school, church, neighborhood, etc.). If you are or ever were to become a leader in this community, what changes would you make? What strengths in the community would you want to preserve? 3) Beyond improving your family’s financial situation and making your parents proud, what are some of the unique reasons you want to earn a college degree? 4) Tell us your story and how that relates to your interest in College Track. What are some qualities and experiences you have that make you unique and a good fit for our program? 5) How do you plan to give back to your community while you’re in high school? When you graduate from college? Optional: In addition to an essay, students are welcome to submit an additional creative piece (poem, drawing, collage, etc.) that allows for more artistic expression. This option is intended for students who express themselves better through the arts. All students are still expected to submit an essay responding to one of the prompts above, as a creative piece will only supplement the application. Any personal items or artwork will be returned at the student’s interview. B: Interest Questions Do you plan to attend college after high school? ! Yes ! No What college/university would you like to attend? What is your best school subject? What school subjects do you need help with? What extracurricular activities are you involved in? Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program. 7 Counselor Recommendation Form* (*Required - If your school does not have a counselor, please give to assistant principal or teacher.) College Track is looking for students who have a strong commitment to their own success. We provide meaningful academic and leadership development activities after school to prepare students for college. As part of the program, students are expected to attend weekly tutoring sessions and participate in workshops, community service projects, and other College Track activities. Please take a few minutes to comment on the student’s character and potential, or you may provide your own letter of recommendation. Thank you. Student Name Your Name School Position Phone Email Your Signature Date Please rate the student’s performance: Excellent (5) Motivation Work habits Quality of work Creativity Ability to work with others Independence Initiative Thoroughness Promptness Self-awareness & expression Leadership Good (4) 1. Does your school consider this student to be an English Language Learner? ! Yes ! No ! Unsure If yes, what level? ! Beginning ! Early Intermediate ! Intermediate ! Advanced ! FEP 2. Does this student qualify for free or reduced lunch? ! Yes ! No Fair (3) Poor (1-2) ! Early Advanced ! Unsure 3. Has the student ever had any behavioral or disciplinary referrals? ! Yes ! No ! Unsure If yes, please explain: ________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program. 8 4. How long have you known the applicant and under what circumstances? 5. To your knowledge, does the student have difficulty processing in one or more areas of learning? ! Yes ! No ! Unsure If yes, please explain: 6. What are the applicant’s strengths? 7. What support system does the student have or utilize at home, on campus, or in the community? 8. How, if at all, has the student changed since you have known him or her? Please return to student in a sealed envelope or mail to: College Track ATTN: CT Recommendation Form 117 Broadway Oakland, CA 94607 Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program. 9 Teacher Recommendation Form* (*Required) College Track is looking for students who have a strong commitment to their own success. We provide meaningful academic and student life services after school to prepare students for college. High academic achievement is not required to apply; yet students have to be on track to complete A-G classes. As part of the program, the student is expected to attend weekly tutoring sessions and participate in workshops, community service projects, and other College Track activities. Please take a few minutes to comment on the student’s character and abilities, or you may provide your own letter of recommendation. Thank you. Student Name Your Name School Position Phone Email Your Signature Date Please rate the student’s performance: Excellent (5) Good (4) Fair (3) Poor (1-2) Motivation Work habits Quality of work Creativity Ability to work with others Independence Initiative Thoroughness Promptness Self-awareness & expression Leadership 1. Does your school consider this student to be an English Language Learner? ! Yes ! No ! Unsure If yes, what level? ! Beginning ! Early Intermediate ! Intermediate ! Early Advanced ! Advanced ! FEP 2. How long have you known the applicant and under what circumstances? Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program. 10 3. Has the student ever had any behavioral or disciplinary referrals? ! Yes ! No ! Unsure If yes, please explain: 4. To your knowledge, does the student have difficulty processing in one or more of several areas of learning? ! Yes ! No ! Unsure If yes, please explain: 5. What are the applicant’s strengths? 6. What support system does the student have or utilize in the classroom, at home, or in the community? 7. How, if at all, has the student changed since you have known him or her? Please return to student in a sealed envelope or mail to: College Track ATTN: CT Recommendation Form 117 Broadway Oakland, CA 94607 Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program. 11 Optional Recommendation Form* (*This form is optional, but if it is completed, it must be from a non-related adult [i.e. coach, community leader, etc.) College Track is looking for students who have a strong commitment to their success and development. We provide meaningful academic and student life services after school to prepare students for college. As part of the program, the student is expected to attend weekly tutoring sessions and participate in clubs, community service projects and various other College Track activities. Please take a few minutes to comment on the student’s character and potential, or you may provide your own letter of recommendation. Thank you for your insight and support. Student Name Your Name School Position Phone Email Your Signature Date Please rate the student’s performance: Excellent (5) Good (4) Fair (3) Poor (1-2) Motivation Work habits Quality of work Creativity Ability to work with others Independence Initiative Thoroughness Promptness Self awareness & expression Leadership 1. How long have you known the applicant and under what circumstances? Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program. 12 2. What are the applicant’s strengths? What makes this student stand out? 3. What support system does the student have or utilize at home or in the community? 4. Describe a time you witnessed this student making an impact. 5. Describe what makes this student an asset to the community. 6. How, if at all, has the student changed since you have known him or her? Please return to student in a sealed envelope or mail to: College Track ATTN: CT Recommendation Form 117 Broadway Oakland, CA 94607 Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program. 13
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