Application - Middle College High School at Volunteer State
MCHS Application Due March 20, 2015 Student Information Student______________________________________________________________________________________ Last Name First Name M.I. Address______________________________________________________________________________________ City _____________________________________________________State________________Zip_____________ Current Sumner County School __________________________________________Current Grade____10 th____11th Age ______Date of Birth _____/_____/_____ Social Security # ____________________________Male ____ Female ____ Home phone ____________________________________ Cell Phone ___________________________________ E-mail Address ___________________________________________________________________________________ Parent(s)/Guardian(s) Mother’s Name _______________________________________________Home Phone ____________________________ Cell Phone ___________________________________ Work Phone___________________________________ E-mail Address _________________________________________________________________________ Father’s Name _______________________________________________Home Phone ____________________________ Cell Phone ___________________________________ Work Phone___________________________________ E-mail Address _________________________________________________________________________ Academic Information How many credits have you earned toward graduation? _________ What is your overall GPA? _____________ What was your last semester’s GPA?______________ Are you in good standing at your present high school? ______Please explain any unusual circumstances. __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ What is your current class schedule? _____________________________ ____________________________ _____________________________ ____________________________ Do you have any ISS or OSS offenses and have you attended R. T. Fisher Alternative High School? Please explain circumstances and provide dates. Please use the back if you need more room. ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ If you are selected to attend Middle College High School, you will be responsible for your own transportation. How do you plan to get to and from Volunteer State? What is your backup plan? __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Please answer the following questions: Did either of your parents graduate from high school? Yes No Is anyone in your immediate family serving or has served in the military? Yes No Is any other language other than English spoken in your home? Yes No Have you ever considered dropping out of school? Explain if yes. Yes No College? Yes No _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Do you feel a lack of belonging at your current school? Explain if yes. Yes No _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Write an essay of at least 150 words stating why you want to attend Middle College High School and how this will impact your future goals? Please attach your essay. This must be typed and written by the student who is applying to MCHS. Send your ACT scores to the address below as soon as you receive notification. Please send a copy of the “View Your Scores” sheet from ACT with your name and ACT showing on the page. Attach a current transcript which you can obtain from your high school counselor, your typed essay and the Parent/Student Agreement form to this application and take or mail to : Middle College High School, Wood Campus Center, Suite217B, 1480 Nashville Pike, Gallatin, TN 37066. DEADLINE March 20, 2015 Counselor ________________________________________ Sumner County Public High School _________________________ Student Name ______________________________________________ (Please Print) Date of Birth ___/___/___ M__F__ I have applied for admission to the Middle College High School program at Volunteer State and have been asked to provide a counselor and principal reference. Student’s Signature____________________________________________ Counselor, all information will be kept confidential. Please complete the sections below and have your principal sign. Please send to the Middle College High School by courier no later than March 20, 2015. You will be receiving teacher recommendations on this student also. Please sent those by courier to the Middle College High School at VSCC. Thank you for your help. How long have you known the applicant? ________________________ Please check the qualities that best describe the applicant: ______ bright/intelligent ______ capable of performing at a higher level ______ demonstrates strong artistic abilities ______ seeks academic challenges ______ desires more freedom or independence ______ participates in class discussions ______ shows leadership abilities ______ eager to join the “adult world” ______ consistent in academic effort ______ good conduct ______ organized time management ______ shows interest in learning ______ mature ______ responsible ______ works independently ______ punctual Please evaluate the student’s current overall performance in each category: Attendance (include tardies): Classroom Attitude: Class Work: Discipline/Work Ethic Potential success in college/ motivated, self starter _____excellent _____excellent _____excellent _____excellent _____excellent ____ good ____ good ____ good ____ good ____ good _____fair _____fair _____fair _____fair _____fair ____ poor ____ poor ____ poor ____ poor ____ poor _____inconsistent _____inconsistent _____inconsistent _____inconsistent _____inconsistent Counselor Signature ______________________________________________ Date____________________ Principal Signature _______________________________________________ Date ___________________ Please use the back of the sheet for additional comments. Sumner County Public School_________________________________ Teacher Name _____________________________ Student Name _____________________________________________( Please Print) Date of Birth ___/___/___ M__ F__ I have applied for admission to the Middle College High School program at Volunteer State and have been asked to provide a teacher reference. Student’s Signature____________________________________________ Teacher, all information will be kept confidential. Please complete the sections below and return it to the high school counselor’s office at your school before March 20, 2015. Do not return to the student. How long have you known the applicant? ________________________ Please check the qualities that best describe the applicant: ______ bright/intelligent ______ capable of performing at a higher level ______ demonstrates strong artistic abilities ______ seeks academic challenges ______ desires more freedom or independence ______ participates in class discussions ______ shows leadership abilities ______ eager to join the “adult world” ______ consistent in academic effort ______ good conduct ______ organized time management ______ shows interest in learning ______ mature ______ responsible ______ works independently ______ punctual Please evaluate the student’s current overall performance in each category: Attendance (include tardies): Classroom Attitude: Class Work: Discipline/Work Ethic Potential success in college/ motivated, self starter _____excellent _____excellent _____excellent _____excellent _____excellent ____ good ____ good ____ good ____ good ____ good _____fair _____fair _____fair _____fair _____fair ____ poor ____ poor ____ poor ____ poor ____ poor _____inconsistent _____inconsistent _____inconsistent _____inconsistent _____inconsistent Teacher Signature ______________________________________________ Date____________________ Please use the back of the sheet for additional comments. Middle College High School at VSCC Parent/ Student Agreement All students at Volunteer State Community College, including Sumner County Middle College students, have access to and can participate in student organizations through Volunteer State Community College except those not approved by VSCC for high school student such as intramurals. Volunteer State has a diverse student population. SCMC students may be attending classes with other students ranging in age from 16 to 80. Parents should contact the SCMC office if they require academic information, as professors are prohibited from discussing students’ information with anyone other than the student. In the event that the student is unable to complete a course (drops, makes an F, or makes a second D) parents are responsible for the price of any books rented through or bought from Volunteer State Community College and the cost of maintenance fees (tuition) for the unsuccessful coursework. Volunteer State has permission to release student grades through email to the Sumner County Department of Education. Midterm grades will be given to parents at the halfway point of each semester. If a student’s grade point average is below 2.0, the student will receive academic probation and the parent/guardian will be required to meet with administration. Final high school transcripts will be released to Volunteer State Admissions and Records. The student has permission to use Counseling and Advisement services at Volunteer State. Students/Parents will not be permitted to register/drop/add classes without advisement from Sumner County Middle College counselor or principal. Students must participate in a Volunteer State sponsored orientation prior to their first semester. Students are expected to: Be prepared for and attend all classes as scheduled; Sign in daily at the SCMC office (Sumner County Attendance Policy); and Exhibit appropriate behavior and attitude in class and on campus. I have read the policies and procedures of Volunteer State and understand that by becoming a Sumner County Middle College student at Volunteer State, I must abide by the high school’s and the college’s rules and regulations. As a dependent of my parents, I give Volunteer State permission to release any information regarding my grades, attendance, academic standing, disciplinary action, or any other aspect of my student life to my parents or legal guardian. _______________________________________________________ ____/_____/________ Student Signature Date of Birth ______________ Date I have read the policies and procedures above and understand that by allowing my child to participate in the Sumner County Middle College program at Volunteer State, I am responsible for following the policies. _______________________________________________________ Parent/Guardian Signature ______________ Date
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