SUMMERBRIDGE SAN FRANCISCO
STUDENT APPLICATION 2014-‐2015 Application deadline: Monday, March 2, 2015 at 5 p.m. ONLY COMPLETE APPLICATIONS WILL BE ACCEPTED ! APPLICATION CHECKLIST:
Student: 
1. Student Information (include recent photo) 
2. Student School Information 
3. Personal Information 
4. Student Essay 
5. Statement of Intent (signed) Parent/Guardian: 
1. Parent/Guardian Information 
2. Family Information 
2 (a). Copy of your 2013 Federal Tax Return 
3. Parent/Guardian Short Answers (2 pages) 
4. Applicant Transcript, Most Recent Report Card and Standardized Test Scores 
5. Recommendation (English Teacher) 
6. Recommendation (Math Teacher) DATES TO REMEMBER!!
Open House – Option #1
Open House – Option #2
Application Due
Applicant & Parent/Guardian Interviews
Final Decision Notifications Mailed
SB New Families’ Saturday
Saturday, January 24, 2015, 1:00 pm - 2:30 pm
Tuesday, February 24, 2015, 6:00 pm - 7:30 pm
Monday, March 2, 2015, 5:00 pm
Saturday March 28, 2015
Friday, April 3, 2015
Saturday, April 25, 2015
Mail or Deliver Completed Application To: Attn: Deundra Hundon, UHS/Summerbridge 3065 Jackson St., San Francisco, CA 94115 1
1. STUDENT INFORMATION
Required: Must be HANDWRITTEN, not typed by student. Use black or blue ink pen, not pencil.
First Name: ________________________ Middle Initial: _______ Last Name: ________________________ Address: ___________________________ City: _______________________ State: CA Zip: __________ Home Phone: ___________________ Student Cell: _______________ Student E-‐mail: __________________ Date of Birth: ___________________ Age: _____ City of Birth: _____________________________________ (mm/dd/yyyy) 5th grade school: ___________________________ 6th grade school: _______________________________ Ethnicity and/or Race: Check all that apply:  African American/Black ¨ Middle Eastern  White/Caucasian ¨ Native American Indian  Pacific Islander ¨ Asian  Latino(a)/Hispanic ¨ Multi-‐Racial ¨ Other: __________________________ Do you have any brothers or sisters? If so, what are their names and ages? Did any of your siblings graduate from Summerbridge San Francisco (University High)? If so, what are their names and what year did he/she attend? Have you participated in any other enrichment program like Summerbridge? (e.g. SMART, 1st Graduate, Aim High) If yes, where and when? 2
ATTACH A RECENT PHOTO OF
YOURSE LF HERE:

2. STUDENT SCHOOL INFORMATION
Current school: Do you find your work at school:  Too Easy  Too Hard What academic subject in school is the hardest for you? Why? Does someone help you with your homework? If yes, who?  About Right 3. PERSONAL INFORMATION
What extra-‐curricular activities do you participate in? Do you play sports for a club, Pop Warner or for an AAU team? If yes, how many days and hours per week do you practice and play? Finish the quote: “One thing that makes me different from most people I know is that I…” Describe something that you learned in school last week/month. What did you learn and why is it important to you? 3
Summerbridge is an academically rigorous six-‐week program during the summer and at least one day a week after school program. In other words we’re a year-‐round enrichment program. Why do you want to spend three summers and after school time here? What do you hope to gain from the program? 4. STUDENT ESSAY (choose one)
Please use a pen to write your response on a separate piece of lined paper. We suggest that you write a rough draft first on a separate piece of paper and proofread for errors. Your essay must be in paragraph structure and 3-‐4 paragraphs. 1. Please describe a problem in your community (neighborhood, school or city) and offer some advice on how you would solve the problem. 2. What are your academic and personal goals for high school and why? 3. If you could have dinner with any person, who would it be? Why would you choose that person? What would you talk to them about? 5. STATEMENT OF INTENT
I understand that Summerbridge San Francisco at University High School is a three-‐year college preparatory enrichment program. I am prepared to make the two-‐year, year-‐round middle school commitment (7th grade and 8th grade). I will attend three consecutive six-‐week summers (7th grade, 8th grade and 9th grade) and the after-‐school program at least one day per week (4:30pm-‐6:15pm). In addition, I will participate in the high school advising opportunities offered by the program. I will maintain a “B” average or above in all of my core classes. I will be present and on time every time I come to Summerbridge. I will commit myself fully by bringing a positive attitude, respect for others, and the ability to work hard and make sacrifices. If I am accepted, my family and I agree not to plan events during the dates and times of the middle school program. _____________________________________________ Student’s Signature _____________________________________________ Parent/Guardian’s Signature 4
___________ Date ___________ Date NAME OF APPLICANT: 1a. PARENT GUARDIAN/INFORMATION (#1)
First Name ____________________________ Middle Initial ____ Last Name ________________________ Relationship to applicant(e.g. mother, father, aunt, grandparent): Address: ______________________________City: _______________________ State: CA Zip ________ Home Phone( ) ________________________ Parent/Guardian Cell ( ) _______________________ Occupation: Employed by: Highest Level of Education Achieved (check one):  Middle School  Some High School  High School Graduate  Some College  Bachelor’s Degree (B.A.)  Master’s Degree or higher Ethnicity and/or Race: Check all that apply (Optional) ¨ Native American Indian ¨ African American/Black ¨ Middle Eastern ¨ White/Caucasian ¨ Asian ¨ Pacific Islander ¨ Multi-‐racial ¨ Latino/Hispanic ¨ Other: ______________________________ 1b. PARENT GUARDIAN/INFORMATION (#2)
First Name ________________________ Middle Initial ______ Last Name ______________________ Relationship to student/applicant (e.g. mother, father, aunt, grandparent):_________________________ 5
Address: City: _______________________ State: CA Zip: __________ Home Phone( ) Parent/Guardian Cell ( ) Occupation: Employed by: Highest Level of Education Achieved (check one):  Middle School  Some High School  High School Graduate  Some College  Bachelor’s Degree (B.A.)  Master’s Degree or higher Ethnicity and/or Race: Check all that apply (Optional) ¨ African American/Black ¨ Native American Indian ¨ White/Caucasian ¨ Middle Eastern ¨ Pacific Islander ¨ Asian ¨ Latino/Hispanic ¨ Multi-‐racial ¨ Other: ______________________________ 2. FAMILY INFORMATION
We require the following information to help us ensure that we are meeting our goal of serving families with limited resources (preference given to low-‐income families). It is very important that you fully complete the following section and provide us with as much information as needed to fully explain your current financial situation. The information that you provide will be kept strictly confidential. Summerbridge is a non-‐profit organization that relies on grants from foundations to fund the program and these foundations often want to know about the background of our students. We only report statistical data, not the identities or financial information of individual families. We are requesting the following information to help insure that Summerbridge assists families that without the program would otherwise not be able to afford the services offered. Does your child qualify for the free or reduced lunch program?  Yes  No Total family gross income:  Less than $10,000  $10,001 – $20,000  $20,001 – $30,000  $30,001 – $40,000  $60,001 – $70,000  More than $90,000  $40,001 -‐ $50,000  $70,001 – $80,000  $50,001 -‐ $60,000  $80,001 – $90,000 6
IMPORTANT AND REQUIRED: Please attach a copy of your 2013 IRS Federal tax returns. (Contact the Summerbridge office immediately with any specific concerns or questions about these documents.) Are there any financial considerations that should be taken into account? Primary languages spoken at home: ___________________________________________________________ Parents/Guardians are:  Together  Separated  Divorced  Widowed Student lives with: _______________________________________________________________________ Additional information that might help us further understand your family situation (Continue on the back if needed): If selected to advance to the Interview round, at least one parent/guardian and applicant must participate in the Summerbridge interview on Saturday, March 28, 2015. The interview will take place at University High School (3065 Jackson St. between Lyon and Baker). The available time slots are 9:00am, 11:00am or 1:30pm. Please indicate your 1st through 3rd choice of times. You will receive a letter after the application deadline confirming your interview time. Indicate your 1st, 2nd, 3rd choice: 9:00am 11:00am 1:30pm 3. PARENT/ GUARDIAN SHORT ANSWERS
Please answer the following in the space(s) provided. You may attach another sheet if you like. How did you hear about Summerbridge?  Middle School Teacher/Counselor  Website  Recruitment Fair  Community Organization or Church  SB Student or Alumni  Other: _______________ Name: __________________________ Name: __________________________________________ 7
Scenario: Your son/daughter plays on a sports team and you just realized that practices and a few games are scheduled on the same day as Summerbridge. What would be your approach to resolving this situation? How would you expect Summerbridge to react to your son/daughter’s extra curricular schedule? Tell us something about your child that hasn’t been described in any other part of the application. What do you feel your child needs to work on, academically and personally? Please comment on any factors that have had an impact on this student’s academic or social progress to date (diagnosed learning challenge(s), Individualized Education Plan (IEP), specialized tutoring). In what activities, community service, sports or arts does you child participate? Please list approximate time spent per activity per week. In what ways do you support or get involved in your child’s education? 8
Why do you wish to see your child enrolled in Summerbridge? During the summer program, we start every morning at 8:00 am. During the school year, our mandatory enrichment classes begin at 4:30 pm. Do you foresee any problems with these times or with daily attendance? (Check one):  No  Yes If yes, please explain any conflicts or concerns: We strongly encourage and welcome parent participation in our Summerbridge Family Association (SBFA -‐-‐
our version of a PTA). In what way(s) will you participate? Parent/Guardian Signature Date REMEMBER THE SUMMERBRIDGE COMMITMENT!! You and your family must agree that, if you are accepted, other activities will be scheduled around the dates of the program. Attendance during the summer and the School Year Program is Mandatory. 9
4. Transcript, Report Card and Standardized Test Scores
Counselor or Principal Form Parent/Guardian: Please complete this form, include your signature below and take it to your son/daughter’s school office. Do NOT submit this form to the Summerbridge Office, see instructions below: 1. Counselor and/or Principal give this form to School Registrar/Secretary; person in charge of transcripts 2. School Registrar/Secretary must provide parent/guardian with transcripts in a sealed envelope 3. Parents submit envelope from School Registrar/Secretary in application packet NOTE: If applicant attends a 6th – 8th grade only middle school, please contact the previously attended school for a copy of his/her 5th grade grades. My child, ____________________________________, is applying to Summerbridge San Francisco, a tuition-‐
free academic enrichment, year-‐round college preparatory program. To School Registrar/Secretary: In order to complete my student’s application for the program, it is required that Summerbridge receive the items listed below by the application deadline Thursday, February 12, 2015 by 5:00 pm. Please provide a copy of the following items, place them in a sealed envelope and return it to the applicant to include in his/her application packet. 1) My son/daughter’s official transcript/grades for the past two years (2013-‐2014 & 2014-‐2015 to date) 2) His/her most current standardized test scores (Include both 5th & 6th grade scores. NOTE: if due to the new Common Core Standards your school is NOT administering standardized tests this year please indicate on the student academic record). If you have questions, please contact Summerbridge at (415) 447-‐3126. If my child is accepted to Summerbridge, I authorize that Summerbridge may have access to her/his grades and test scores for her/his remaining school years. Thank you, ______________________________________________ _____________________ Parent or Guardian Signature Date 10
5. Recommendation (English Teacher)
Summerbridge San Francisco New Student Application -‐ English Teacher Recommendation (Page 1 of 2) To the Parent/Guardian: Complete the top portion of this form and give it to your child’s current teacher. Name of Applicant: _________________________________________________________________ first middle last Today’s Date: ________________ Current Grade: ________ month day year I, parent/guardian, hereby give permission for you to release the information on this form concerning my child. I understand that I will not have access to this confidential information. ___________________________________ ___________________________________ Parent/Guardian Name Parent/Guardian Signature To the Student’s Current Teacher: The above-‐named student is applying to Summerbridge, a tuition-‐free, academic enrichment and advocacy program for motivated 6th through 9th grade students. The program consists of three consecutive six-‐week summer sessions, starting the summer before 7th grade. To assist us in deciding if our program suits this student’s educational needs, we ask you to complete and return this descriptive form. We would appreciate your candid responses; all recommendations are kept confidential. Please feel free to add additional comments where you see fit. If you have questions, please contact Deundra Hundon at 415.447.3126 or [email protected]. Please return this form in a sealed envelop to your student or directly to Summerbridge no later than Thursday, February 12, 2015. 1. Academic potential  limited  fair  good  outstanding 2. Academic achievement  below expectations  as expected  better than expected  far above expectations 3. Effort/Motivation  limited  sporadic  usually good  exemplary 4. Study habits  poor  fair  good  excellent 5. Ability to work in groups  has great  sometimes has  usually effective  always works well difficulty 6. Ability to work alone  rarely able to work  sometimes able  often able to help to work without help work without help  consistently able to work without without help 7. Curiosity  little  occasional  consistent  marked 8. Ability to express ideas orally  limited  has some  good  exceptional 9. Ability to express ideas in writing  limited  has some difficulty  good  exceptional writing
10. Imagination  little  fair  active  highly developed 11. Use of time 12. Follows directions  uses poorly  occasionally  usually uses well  always uses effectively wastes  rarely  needs repeated  occasionally explanations needs help  quickly and effectively  rarely  occasionally  usually  always difficulty 13. Seeks help when needed difficulty 11
 easily distracted  occasionally  usually good  exceptionally good  very immature  somewhat  mature impressive 16. Respect for others  often disrespectful  usually respectful  respectful  highly respectful 17. Social interactions with peers  relates poorly  occasional issues  healthy  exemplary  poor  fair  a follower  leads when given  seeks responsibility opportunities and uses them well 14. Attention span 15. Maturity in terms of age/grade 1118. Reaction to criticism 19. Leadership potential immature Relationships  good  excellent  a natural leader  rarely  occasionally shows initiative initiates occasional misconduct  good  exemplary conduct  fair  good  delightful  needs much  avg needs  avg appears  positive self-‐image 24. Reading comprehension  below average  average 
good  excellent 25. Writing  below average  average  good  excellent 26. Math fundamentals  below average  average  good  excellent  yes  no 20. Initiative 21. ClaClassroom conduct 22. Sense of humor  never initiates distracted frequent disruptions  rarely laughs or behavior  often initiates smiles 23. Self confidence reassurance some support 27. Is this student in the GATE (gifted and talented) or Pre-‐AP program? overly confident Additional Comments: Please describe the family’s relationship with the faculty and administration: Is there any additional information that could be better conveyed in a phone or email conversation?  Yes, I would like a follow-‐up conversation  No Are you familiar with the Summerbridge at University High School program?  Not at All  Somewhat  Fairly  Very Familiar Specific Recommendation (please keep in mind that our program is very academically rigorous):  Highly recommended  Recommended  Recommend with reservations  Prefer not to make a recommendation  Not recommended Form completed by: _______________________________ Position: ___________________________ Email: ___________________________________________ Phone: ___________________________ Subject(s) you taught applicant: __________________________ I have known applicant for: __________ School: _____________________________ School Phone: __________________ Date: _________ 12
6. Recommendation (Math Teacher)
Summerbridge San Francisco New Student Application -‐ Math Teacher Recommendation (Page 1 of 2) To the Parent/Guardian: Complete the top portion of this form and give it to your child’s current teacher. Name of Applicant: _________________________________________________________________ first middle last Today’s Date: ________________ Current Grade: ________ month day year I, parent/guardian, hereby give permission for you to release the information on this form concerning my child. I understand that I will not have access to this confidential information. ___________________________________ ___________________________________ Parent/Guardian Name Parent/Guardian Signature To the Student’s Current Teacher: The above-‐named student is applying to Summerbridge, a tuition-‐free, academic enrichment and advocacy program for motivated 6th through 9th grade students. The program consists of three consecutive six-‐week summer sessions, starting the summer before 7th grade. To assist us in deciding if our program suits this student’s educational needs, we ask you to complete and return this descriptive form. We would appreciate your candid responses; all recommendations are kept confidential. Please feel free to add additional comments where you see fit. If you have questions, please contact Deundra Hundon at 415.447.3126 or [email protected]. Please return this form in a sealed envelop to your student or directly to Summerbridge no later than Thursday, February 12, 2015. 1. Academic potential  limited  fair  good  outstanding 2. Academic achievement  below expectations  as expected  better than expected  far above expectations 3. Effort/Motivation  limited  sporadic  usually good  exemplary 4. Study habits  poor  fair  good  excellent 5. Ability to work in groups  has great  sometimes has  usually effective  always works well difficulty 6. Ability to work alone  rarely able to work  sometimes able  often able to help to work without help work without help  consistently able to work without without help 7. Curiosity  little  occasional  consistent  marked 8. Ability to express ideas orally  limited  has some  good  exceptional 9. Ability to express ideas in writing  limited  has some difficulty  good  exceptional writing
10. Imagination  little  fair  active  highly developed 11. Use of time  uses poorly  occasionally  usually uses well  always uses effectively wastes 12. Follows directions  rarely  needs repeated  occasionally explanations needs help  quickly and effectively  rarely  occasionally  usually  always difficulty 13. Seeks help when needed difficulty 13
 easily distracted  occasionally  usually good  exceptionally good  very immature  somewhat  mature impressive 16. Respect for others  often disrespectful  usually respectful  respectful  highly respectful 17. Social interactions with peers  relates poorly  occasional issues  healthy  exemplary  poor  fair  a follower  leads when given  seeks responsibility opportunities and uses them well 14. Attention span 15. Maturity in terms of age/grade 1118. Reaction to criticism 19. Leadership potential immature Relationships  good  excellent  a natural leader  rarely  occasionally shows initiative initiates occasional misconduct  good  exemplary conduct  fair  good  delightful  needs much  avg needs  avg appears  positive self-‐image 24. Reading comprehension  below average  average 
good  excellent 25. Writing  below average  average  good  excellent 26. Math fundamentals  below average  average  good  excellent  yes  no 20. Initiative 21. ClaClassroom conduct 22. Sense of humor  never initiates distracted frequent disruptions  rarely laughs or behavior  often initiates smiles 23. Self confidence reassurance some support 27. Is this student in the GATE (gifted and talented) or Pre-‐AP program? overly confident Additional Comments: Please describe the family’s relationship with the faculty and administration: Is there any additional information that could be better conveyed in a phone or email conversation?  Yes, I would like a follow-‐up conversation  No Are you familiar with the Summerbridge at University High School program?  Not at All  Somewhat  Fairly  Very Familiar Specific Recommendation (please keep in mind that our program is very academically rigorous):  Highly recommended  Recommended  Recommend with reservations  Prefer not to make a recommendation  Not recommended Form completed by: _______________________________ Position: ___________________________ Email: ___________________________________________ Phone: ___________________________ Subject(s) you taught applicant: __________________________ I have known applicant for: __________ School: _____________________________ School Phone: __________________ Date: _________ 14