1. family and parenting
2. children

Note to r1/I~SD Princi ads with 5~h Grade Low-income Scholars
Please mail Columbus Scholars Applications by
Friday October 24, 2~~4 to:
c/o Melanie Slaton-Holden
Hatcher, Stubbs et. al.
P.Q. Box 2707
Columbus, GA 31902-27Q7
Call ben Holden with Questions at
4706} 332-8420 or email BenHo(d~n~l~~mail.com
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~ 11II1 ~.1S
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•Wl1e~e mentorin~ meets hope•
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BIG BRUTHERS BlG SISTERS
o~n~c~rr~HOCva~r
A~PPLICATI~N F4R COLUMBUS SC~OLA►l~S PRtJJECT
Please use open -- all signatures MUST be Yn inl~
Child's Fuld Name:
~'lR.ST
Birth date: ______ I
I.~4ST
MIDDLE
I
Gender: ❑ M ❑ F
Age:
Apartment #:
address:
City:
Home Phone:
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Email Address:
Zip:
State:
Work Phone:
-
Ce1~ Pone:
-
-
Child's Sc~iool:
-
Grade:
'here do you plan for chip.to go to middle school`?
~nformat~oa About The Family:
Custodial Adult:
Age:
Please describe }your household:
❑ Single-parent household
Q Two-parent ~.~usehold
~'Iease chick all that apply: Child has...
❑ a parent or guardian currently employed
❑ a parent currently incarcerated
[~ ether {i.e. relative other than parent}
Marital Status: you are cunrentl~...
Q Single
❑ Nlarnied ❑Separated
What is your relationship to the child?
❑Father ❑Grandparent
Ma#her
Divorced Q Widowed ~]~..iving with someone
Q Fos~~r parent ❑Sher:
Tact All mpmherc rtif vni~r hn~~cc~hnlrl- tinrlizrlp cihlinuc anr~ ntherc livinsr with vn~~ Anrl v~~~r chiltll
Name
iZe~ationsh~ to Child
Uceu ationlSchool
e
1,
2.
3.
4.
emergency Contact:
tQther than yaurse~
Phflne #:
11~A.~E
~n~ployer:
REI~7'ID~SHl~' TO ~'HILD
Job Title:
Have you or your child received for are you and you child currently receiving)any professional help from other
agencies, schools, psychiatrists, psychologists, social workers,etc? If yes, please indica.~e: Name, Address,PhoMe
Number,and Dates.
~.
2.
Informat~an About The Absent Parent:
Name:
Age:
Race;
Where ~s he/she currently living?
Does he/she have contact with the child? ❑Yes ❑ No
Whey did the child Last see the absent parent?
If yes, how o$en?
Does the absent parer# have legal visiting rights? Q Yes ❑ No
To be comple#ed bar School Princ~p~lw
Pease affirm #hat the Applicant is eligible far the National Schoa~ ~.unch Program,federal Secno~ 8 hc3using subsidy or assistance,
Aid to Families with Dependent Children or an egwivalent indicator offinancial need.
meets one or mare ofthe above-listed criteria.
I affirm that
Student Nome
Sclrool ~'rineipal's Prated Name
~rxte
Signatr~re
~
Ph~rte Number
Email
Reiea~ Autbor~~oa and Covenant Tat fo Sue by Guardian or Parent:
I hereby request that my child or ward named above who is a student i~ ~uscogee Count}r School district{1ViCS~} be included
in the
Ius/her
Big Brothers Big Sisters ofthe Chatta~ooche,~ Valley ~3BBSCV~ I Columbus Scholars,Inc.(CS} ~Srogram and consent to
"
par~cigation in any activity offered by the program_ I fiu.~ther agree that some ~forma~ian contained herein and other information
MCSD.
and
CS
BBBSCV,
Sister,
gathered shall be shared with the pmspec#ive Big BrotherBig
child or
I understand that I am free to withdraw my gild=s or ward's application for service at any time and nay also v~#hdravv my
ward from the program at any #ime I wish. I further under:~tand that BBBSC~TICS may not be able to complete a match with a
volunteer for my child or ware.
I do hereby wive any and aIi privacy rights, restirictions ar~d interests in the student data, grades, materials or other
information
pertaining to my child or ward with MCSD applying only in as rr~uch as such waiver allows ~S and ids Board member and BBBSC~
ofthe ~fCSD.
to obtain,analyze and discuss any school records ofany IYICSD school and related records with any and aII employees
by CS
I fur~hec agree to provide my grades and any other academic performance materials including `parent portal' access)requested
an~lar BBBS~V.
the
I will allow Columbus Scholars or a BBBSC'~ representative to be t ie primary contact on the MCSD `parent portal' site and
contact.
mentor to be the secondary
this
In additional consideration ofmy child's or ward's participation in the BBBSCVICS or sponsored activities and submitting
app~i~ation,I do covenant that I vw~ii not make claims or demands for myselfor on beha~+of my eh~t~d or ward against
B~3~3SC~l/~S/IViC~D, The Family Center,their ~rofessionai staffs, or any hoard n~e~rnber thereof whici~ may occur du.ri~g
participation directly ar induecti~ in the activities ofthe program and this a~p~~cation process.
I also agree to release and hotel har~mle~s and school wi#h the MCSfJ,CS,BBBSC~ acid heir ploye~es, Board memb~e~rs anti agents
from all ciainas, lawsuits or privacy rights of mine or those of my child or ward under any federal, s~.ate ~r ~acai pr~va~y ar r~la~ed
statute.
I understand that as guardian ar parentthatI wild b~ responsible to gu~ara~atee that my child or ward will ~e transported to and will
ant~/or
a#tend SS`s Acad~rnic ~urnmer Camp as directed by the board ofC5,scboo~-dear iutorial sessions as deemed necessary by CS
BBBSC~',ail ~nonth~y enric~m~nt sessions and any other GS requited programs by either p~rov~dtng transportation or har~ng ~vmeone
else get my chid or wazd -~a tie e~ event.
I also understand that ~fmy child or ward is seiect~d, both ofurs Ali sign a commitment letter s~nular to the one ~os#ed on the CS
website which requires my child or ward to maintain a B average, t~ nom# engage in any inappropriate beha~or and to support CS,
I also ur~ders~and t~iat my child ar v~rard vv~Il be required to apply for and then attend Arnold N~iddle School MagnetProgram or
Richards Middle Scho+~i ~ ~'nogram and that my child or ward will be required to app~~ for and then attend Columbus High School
Magnet Progxam or Hardaway High Schao~ IB Progra~n~urthermore,the s~gna~ure belov~ indicates that I give permission to the BBBSC'~~~5 to pho~graph, videotape, and publicize the
accomplishr~aents of my chid or ward for ~~ limited purpose a~pu~lic g a~u dui~u~~=~1~ the ~c~r~C ofthe 8~~~~~/~S.
I have read, understand,an d agree #a the above release, author~zat~on and covenant not to sue for my child's or ward's
eligibility and participation in tine ~BBS~YfCS program.
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.P~4REN~/~U~f~.~.1V ~.~GNA7'U~E`
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D~i~'E
Please assure that this appiicat~on includes the fvIIQw~i~g:
❑STATE~NT OF R~~01~~1~Il~ATION~: Attach se~~rate sheet,felling us something above the s~uden~ and vvhy he~she v~ould
make a good Columbus Scholar_ (for ex$mpie: Student is resi~e~t,coming from asingle-parent amity home. He/She has a B +
average, I~~res frog and math, and always tools at the bright side ofthings.} (Pro~de name,email and phone n~unber of person
making recommendation.}
GRADES: Attach a copy oftranscript shoving grades from prev~aus years and current year.
[~A~~VEMENT TEST SC4~t.ES: Attach a copy of Achiever3nent Test Scores from previous year.
]ESSAY REC~IJIREMENT: Topic — `why I Want ~`o Ga To College" teinphasizing hurdles the student has overcome}. One
standard 8.5 x 11 inch page,typewritten, double-spaced. The essay rnus~ solely be the student's work. Thought attd Ydeas are more
impnr#ant than grammar.
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o m~r~ than ~ a Iicat~Qns r elemen
sc~ioo~ shall be s
'tted,