PLUS Summer Enrichment Program at Berry College

Transcription

1 PLUS Summer Enrichment Program at Berry College Personal Information Full Name: Last First M.I. Street Address Apartment/Unit # City State ZIP Code Home Phone: Alternate ( ) Phone: ( ) Name of High School: Birth date: Parent(s) Name(s): Parent(s) Phone Number: Parents Predominant ethnic background: Gender: GPA (on a 4.0 scale): Additional Information African American/ Non-Hispanic Hispanic Asian or Pacific Islander American Indian Multi-racial White/Non-Hispanic Female Male Grade Level: Parent(s)Cell Phone Number: ( ) Have you taken the SAT/ACT? Emergency Contact Information Yes No If yes, when did you take it? Verbal Please include your SAT/ACT scores: Math Writing Full Name: Street Address City State and Zip Code Primary Phone: ( ) Alternate Phone: ( ) Relationship: For Office Use Only Received Interview

2 PLUS Summer Program 2015 As part of the application process for colleges and/or universities, students are often asked to answer essay questions. Please respond thoughtfully to the following questions. They are designed to give you an opportunity to relate your experiences that qualify you to participate in the PLUS Summer Program. Each answer should be no more than 200 words each. Attach your responses to this application. 1. What are the three (3) talents, skills, or ideals you would like to develop during the program? Why? 2. The core of this program is to create a support and guidance system for college admission. What are your top three (3) colleges or universities you would like to attend? Why would you choose those 3 colleges or universities? 3. As you plan for college and/or university admission, what is your anticipated major? Or minor? Why? 4. Why are you interested in the PLUS Enrichment Program? What do you hope to learn? 5. Name a person who has inspired you to pursue post-secondary education. Briefly describe how he or she has challenged you.

3 Statement of Application I affirm that all information supplied is complete and accurate. I further attest that to the best of my knowledge all of the information I have supplied in this application, or will subsequently submit, is complete and accurate and that any omission or misrepresentation will invalidate any further consideration or subsequent admission. Additionally, I understand and agree that I will be bound by the PLUS Enrichment Summer Program regulations concerning admission requirements, including all application and enrollment deadlines. Signature of Applicant Signature of Parent (if applicant is under the age of 18 years old) I hereby acknowledge that the PLUS Summer Program may verify the information set forth herein (from sources accessible under the law to the institution) pursuant to reasonable inquiry where needed. If I am selected and admitted into the PLUS Summer Program at Berry College, I agree to abide by all Berry College policies and regulations and those set forth by the PLUS Summer Program. Signature Signature of Parent (if applicant is under the age of 18 years old)

4 Checklist of application materials for the PLUS Summer Program Completed, signed application Two (2) forms of recommendations: one (1) from nominating high school guidance counselor and one (1) from a teacher An original or certified copy of your high school transcript Deadline is April 20, 2015 to Multicultural and International Student Programs

5 Counselor Recommendation Form MISP Office P.O. Box Mount Berry, GA To the Applicant: After completing the information below, please give this form to your high school counselor. Applicant name: Last First Middle (spell out) Street City, State Postal Code To the Counselor: Please complete the form and return it to MISP Office, Berry College, P. O. Box , Mount Berry, GA or return it to the applicant to be included in the application packet. High school graduation date This candidate ranks in a class of students and has a cumulative grade-point average of on a scale. In comparison to other college-preparatory students at your school, the applicant s course selection is: most demanding demanding average less demanding than average Has this student ever been placed on academic or disciplinary probation or suspension from any secondary school? yes no unable to answer How long have you known the applicant, and in what context? Compared with other college-bound students with whom you have experience, please indicate your perception of the applicant s attributes by circling the appropriate number in the range indicated below. Very unsatisfactory Excellent NA Academic preparation Work ethic Initiative Leadership Concern for others Emotional stability Respect for others beliefs Acceptance of diversity Integrity Service to others

6 Please describe the student s academic and personal characteristics as they may pertain to the potential for success as a college student. (You may attach an additional sheet if necessary.) I recommend this student: with reservation with no reservation highly recommend Counselor s name (please print or type): Signature: Title: School: Counselor s address: Office phone: / Office fax: High school CEEB/ACT Code:

7 Teacher Recommendation Form MISP Office P.O. Box Mount Berry, GA To the Applicant: After completing the information below, please give this form to a teacher who would be qualified to comment on your aptitude for success as a college student. Applicant name: Last First Middle (spell out) Street City, State Postal Code To the Recommender: Please complete the form and return it to MISP Office, Berry College, P. O. Box , Mount Berry, GA or to the applicant to be included in the application packet. How long have you known the applicant? In what context do you know the applicant? Compared with other college-bound students with whom you have experience, please indicate your perception of the applicant s attributes by circling the appropriate number in the range indicated below. Very unsatisfactory Excellent NA Academic preparation Work ethic Initiative Leadership Concern for others Emotional stability Respect for others beliefs Acceptance of diversity Integrity Service to others Please provide any additional information you believe would be important for Berry to know about the student and his or her aptitude for success as a college student. (You may attach an additional sheet if necessary.) I recommend this student: with reservation with no reservation highly recommend Recommender s name (please print or type): Signature: Title: Place of employment Daytime phone: / address: