International Baccalaureate Programme Application For entry in fall 2015 Middle Years & Diploma Programme Lucille Brown Middle School (rising 6 th, 7 th, & 8 th Grade admittance) Thomas Jefferson High School (rising 9 th & 11 th Grade admittance) APPLICATION DUE to zone middle school counselor January 15, 2015
Proof of Residence To be eligible to apply you must reside within Richmond City. Proof of residence will be verified once students are admitted to the program. Acceptable documentation of proof of residency must include portion of rental/mortgage agreement that displays your name and address and a copy of your driver s license showing the same address. Both documents are required. If you change your residence at any time, you must notify the Office of Gifted Programs immediately at (804) 780 7805. Please include with your application! Final report card from 2013-14 school year! 1 st Semester report card from 2014-15 school year! Written documentation of testing accommodations or IEP/504! 1 Adult recommendation! 1 Teacher recommendation Additional information submitted will not be evaluated. Incomplete applications will not be processed. For admission in Fall 2015 2
General Information To be completed by all applicants. Name: Last First Middle Initial Birth date: / / Grade: Student ID #: Gender M F Home Address: (No P.O. Box # s) City State: Zip Primary contact phone #: Current School: School Phone Public or Private (circle one) Are you Hispanic? Yes No Enter the two-digit race code from the next page. Race Code: In which middle school s zone do you live? Parent/Guardian Name(s): Father s Work Phone #: Mother s Work Phone #: Primary contact email(s): Emergency Contact Person: Phone #: By signing this form, I verify the fact that I am a resident of Richmond City and that all information submitted is accurate to the best of my knowledge. I also consent to allow my child's academic records and disciplinary files evaluated and to allow him/her to participate in interviews and tests sessions for admission. Student Print Sign Date Parent/Guardian Print Sign Date For admission in Fall 2015 3
Virginia s Ethnicity and Race Categories Question 1: Is this student Hispanic or Latino (a)? (Choose yes or no and place on the front of this page.) No, not Hispanic or Latino Yes, Hispanic or Latino (a) (a person of Cuban, Mexican, Puerto Rican, South American, Central American, or other Spanish culture or origin, regardless of race) Question 2: What is the student s race? (Choose code(s) below, and place on the front of this page.) One Race 00 Unspecified 01 American Indian/Alaska Native 02 Asian 03 Black or African American 04 Hispanic 05 White 06 Native Hawaiian/Other Pacific Islander Combination of Two Races 07 American Indian/Alaska Native AND Asian 08 American Indian/Alaska Native AND Black or African American 09 American Indian/Alaska Native AND White 10 American Indian/Alaska Native AND Native Hawaiian 11 Asian AND Black or African American 12 Asian AND White 13 Asian AND Native Hawaiian 14 Black or African American AND White 15 Black or African American AND Native Hawaiian 16 Native Hawaiian and White Combination of Three Races 17 American Indian/Alaska Native, Asian AND Black or African American 18 American Indian/Alaska Native, Asian AND White 19 American Indian/Alaska Native, Asian AND Native Hawaiian 20 Asian, Black or African American AND White 21 Asian, Black or African American AND Native Hawaiian 22 Black or African American, White AND Native Hawaiian 23 Black or African American, Native Hawaiian AND American Indian/Alaska Native 24 White, Black or African American AND American Indian/Alaska Native 25 White, Native Hawaiian AND American Indian/Alaska Native 26 White, Native Hawaiian AND Asian Combination of Four Races 27 American Indian/Alaska Native, Asian, Black or African American AND White 28 Asian, Black or African American, White AND Native American 29 Black or African American, White, Native Hawaiian AND American Indian/Alaska Native 30 White, Native Hawaiian, American Indian/Alaska Native AND Asian 31 Native Hawaiian, American Indian/Alaska Native AND Asian Combination of Five Races 32 American Indian/ Alaska Native, Asian, Black or African American, White AND Native Hawaiian For admission in Fall 2015 4
Adult Recommendation An adult, other than a parent or guardian, who knows the student well, should complete this form. Student s Name: Last First Middle Initial Recommender s Name: What is your relationship to this child? Your recommendation is an important part of the application process. Please be honest in your evaluation. If you do not feel comfortable recommending this student, please return the form to the student or the school counselor immediately. Return your completed recommendation to the school counselor by January 15, 2015. Put a checkmark in the box that represents the frequency of the student s behavior for each prompt. Rarely Occasionally Frequently Retains and understands information quickly Understands and uses information correctly Has unique and/or innovative ideas Has a sustained focus on topics of interest Recognizes patterns and find solutions Visualizes information and learns by doing Is able to persist in the face of difficulties to accomplish self-set goals Recognizes and responds to the needs of others Motivates, inspires, and/or influences others Adult s Signature: Date: Adapted from Teachers Observation of Potential in Students (TOPS; Coleman, Shah-Coltrane, and Harrison, 2003) For admission in Fall 2015 5
Teacher Recommendation A current classroom teacher should complete this form. Student s Name: Last, First Middle Initial Teacher s Name: School: Grade: Subject(s) you teach to this student: Rate your impression of the student relative to the following item descriptors. Indicate your rating by circling the appropriate number. Do not place circles between two numbers. Base your ratings on your knowledge of and experience with all the students you have known who are the targeted student s age. When rating each item, think about the student as compared to his or her peers. Intellectual Ability Below Average Above 1. Learning facts quickly 1 2 3 4 5 6 7 8 9 2. Comprehending abstract ideas and concepts 1 2 3 4 5 6 7 8 9 3. Enjoying challenging problems 1 2 3 4 5 6 7 8 9 4. Making quick and valid generalizations 1 2 3 4 5 6 7 8 9 5. Reasoning things out 1 2 3 4 5 6 7 8 9 6. Grasping relationships between subjects 1 2 3 4 5 6 7 8 9 7. Solving difficult and unique problems 1 2 3 4 5 6 7 8 9 8. Generating sophisticated ideas and solutions 1 2 3 4 5 6 7 8 9 9. Using generalizations in new situations 1 2 3 4 5 6 7 8 9 10. Choosing and completing difficult and challenging tasks or 1 2 3 4 5 6 7 8 9 problems Total Score: Academic Skills Below Average Above 1. Learning information and skills quickly 1 2 3 4 5 6 7 8 9 2. Comprehending complex and difficult material 1 2 3 4 5 6 7 8 9 3. Knowing the correct answer without always being able to explain processes which achieved the answer. 1 2 3 4 5 6 7 8 9 4. Maintaining intense and sustained interest in a subject 1 2 3 4 5 6 7 8 9 5. Self-motivation to learn 1 2 3 4 5 6 7 8 9 6. Self-directedness 1 2 3 4 5 6 7 8 9 7. Correcting his or her own errors 1 2 3 4 5 6 7 8 9 8. Recognition by peers as having high intellectual ability 1 2 3 4 5 6 7 8 9 9. Recognition by other teachers as bright and achieving 1 2 3 4 5 6 7 8 9 10. Self-awareness about his or her academic aptitude 1 2 3 4 5 6 7 8 9 Total Score: For admission in Fall 2015 6
Teacher Recommendation pg. 2 Students Name Leadership Below Average Above 1. Leadership among his or her peers 1 2 3 4 5 6 7 8 9 2. Being liked by peers 1 2 3 4 5 6 7 8 9 3. Persuasiveness in talking to others 1 2 3 4 5 6 7 8 9 4. Getting along with others 1 2 3 4 5 6 7 8 9 5. Ease in working in groups 1 2 3 4 5 6 7 8 9 6. Influencing the behavior of others 1 2 3 4 5 6 7 8 9 7. Working effectively with peers 1 2 3 4 5 6 7 8 9 8. Sociability; enjoying being around other people 1 2 3 4 5 6 7 8 9 9. Ease in participating in groups activities 1 2 3 4 5 6 7 8 9 10. Actively participating in group decision making 1 2 3 4 5 6 7 8 9 Total Score: II. Check the response that best describes your recommendation. I feel confident recommending this student I recommend this student with reservations III. This student is self-disciplined. needs adult intervention to maintain appropriate behavior. has behavioral difficulties. Teacher s Signature: Date: Teacher, please return your completed recommendation to the school counselor. For admission in Fall 2015 7
In accordance with federal laws, the laws of the Commonwealth of Virginia and the policies of the School Board of the City of Richmond, the Richmond Public Schools does not discriminate on the basis of sex, race, color, age, religion, disabilities or national origin in the provision of employment and services. The Richmond Public Schools operates equal opportunity and affirmative action programs for students and staff. The Richmond Public Schools is an equal opportunity/affirmative action employer. The Title IX Officer is Mrs. Angela C. Lewis, Clerk of the School Board, 301 N. 9th St. Richmond, VA 23219-1927, and 804.780.7716. The Section 504 Coordinator is Dr.. Michelle Boyd, Director of Exceptional Education and Student Services, 301 N. 9th St., Richmond, VA, 23219-1927, 804.780.7911. The ADA Coordinator is Ms. Valerie Abbott-Jones, 2015 Seddon Way, Richmond, VA 23230-4117, and 804.780.6211. The United States Department of Education's Office of Civil Rights may also be contacted at 550 12th Street SW, PCP-6093 Washington, DC 20202, (202) 245-6700. SCHOOL BOARD Donald Coleman - Chair Kristen Larsen - Vice Chair Glen Sturtevant Jeffrey Bourne Kimberly Gray Tichi Pinckney Epps Mamie Taylor Derrick Jones Shonda Harris Muhammad Dr. Dana T. Bedden Superintendent For admission in Fall 2015 8