STEP Application Checklist

2017-2018 STEP Application Checklist Be sure to complete all required sections of your child s application before submitting it to the STEP Office for processing. Failure to do so will delay his/her acceptance notification. This form can be completed electronically. Please print the completed application and verify that all pages are signed before submitting to the STEP office. All Students Application Checklist Student Application Form All 3 sections complete - (Student, Contact & Emergency Contact Info) Page 1 Student Application Form Parent and Student signatures (Bottom of page) Page 1 Student Authorization for Disclosure of Educational Information Ensure all 3 check boxes are marked in the top section (within the red box) Ensure the student s school name is entered (within the red box) Page 2 Verify Parent/Guardian Signature (Bottom of page) Student Questionnaire Be sure to select Yes or No for every question. Page 3 Informed Consent Form Parent & Student signatures (Bottom of page) Page 3 STEP Program Contracts & Agreements - Parent & Student signatures below Statement of Understanding Page 4 Official Copy of Student s Grades Provide either the student s academic transcript or a copy of student s final report card for school year ended June Attachment 2017. NEW STUDENTS ONLY ADDITIONAL ITEMS REQUIRED Income Verification Page ONLY REQUIRED if you select as your ethnicity: Native Hawaiian/Pacific Islander, Asian (Excluding Pacific Islanders), White/Caucasian, or Other. Income Verification Documents appropriate documents attached (refer to bottom of page 5 for details) Recommendation Form Provide the final page of this packet to an acceptable party so that they can complete the Student s recommendation. Page 5 Page 5/ Attachment Page 6 APPLICATIONS ARE REVIEWED ON A ROLLING BASIS. SUBMIT APPLICATION VIA EMAIL, FAX, or MAIL: Email: step@syr.edu Fax: (315) 443-5683 Mail to: 419 Sims Hall, Syracuse, NY 13244 STEP 2017-2018 Application for Print Checklist

2017-2018 Student Application Form In order to be eligible for the STEP program, the applicant must have been a resident of NY State at least 12 months prior to application and must be enrolled in grade 7-12 for the 2017/2018 academic year. Section 1: Student Information Last Name First Name M.I. Grade 7 8 9 Home Address Street Address (September 2017) (Select one) City State Zip Code 10 11 12 NYSSIS Code (From guidance counselor) Home/Primary Phone # ( ) - T-Shirt Size (Select One) S M L XL XXL 3XL 4XL Date of Birth Age Gender Male Female Ethnicity (Select all that apply) ** Complete Page 5 if selected Hispanic/Latino Alaskan Native/American Indian Asian (excluding Pacific Islanders)** Black/ African American New York State Resident? Yes No If yes, since when? Country of Birth (if other than USA) Native Hawaiian/ Other Pacific Islander** White/ Caucasian or Other** Permanent Resident Alien? Yes No If yes, Registration number: Section 2: Contact Information Mother s Name/Guardian* Cell Phone: E-mail Address: Father s Name/Guardian* Cell Phone: E-mail Address: Student s Name Cell Phone: E-mail Address: Section 3: Emergency Contact Information Name Home Phone Cell Phone Relationship to Student * To the Parents/ Guardians: Your signature on this application guarantees that all the information within this application is accurate and complete to the best of your knowledge in accordance with Federal and State regulations. Parent/Guardian Signature Date Student Signature Date STEP 2017-2018 Application for Print Page 1

2017-2018 STEP Student Authorization for Disclosure of Educational Information This page must be completed in full in order to be eligible for STEP Program acceptance. Student Name: Grade School Name: I AM: The person legally responsible for the above named individual and I authorize the Science and Technology Entry Program to: OBTAIN INFORMATION FROM: (Please indicate your specific school in Onondaga County) RELEASE INFORMATION TO: Syracuse University Science and Technology Entry Program (STEP) 419 Sims Hall Syracuse, NY 13244 I hereby authorize the disclosure of educational information between the Science and Technology Entry Program (STEP) and the School district indicated above, in accordance with the Family Educational Rights and Privacy Act (FERPA). Specific information to be released or obtained includes the following confidential information necessary for educational services: - Student standardized test scores, Grades, and Report Card Information - New York State Student Identification System (NYSSIS) ID which is also known as the Student State ID. - Attendance Data and Suspension Data - Information on a Student s Individual Education Plan (IEP) - Teacher/administration notes and correspondence - Individual course communications, assignments, and interim results - Other This information is required for the purpose of any necessary and ongoing educational needs inclusive of evaluations and recommendations for further development. By signing below I am stating that: - I understand the information disclosed, as permitted by this authorization, will not be re-disclosed by the receiving entity (and/or its affiliates). I do understand that local, state, and federal laws do exist to protect the confidentiality of this information. - I understand that I have the right to revoke and/or restrict this authorization at any time without penalty, provided that I submit a request in writing to the STEP Office. - I authorize the periodic, on-going disclosure of the above information. This authorization expires one year after date of signing or at disenrollment from services, whichever comes first. Re-authorization will be obtained after one year if information is still needed. Parent/ Guardian (Print Name) Parent/Guardian Signature STEP 2017-2018 Application for Print Page 2 Date

2017-2018 Student Questionnaire Be sure to respond to all questions on this page. Information below is required by the New York State Education Department which provides funding for the STEP Program. Student Name: Grade Is student presently enrolled in another program? (LeMoyne or OCC, STEP or LPP) Yes No Is student presently enrolled in Syracuse Challenge? (Syracuse City School District Only) Yes No Does student have an IEP or 504 Plan? (Individualized Education Program) Yes No Is student eligible for free or reduced lunch? Yes No Please indicate if you or your family members are recipients of the following (select all that apply): Aid to Dependent Children Yes No Family Assistance Program Aid Yes No Family Day Care through Social Services (New York State Office of Children and Family Services Assistance/ Onondaga County) Ward of the State or County Yes No Living with foster parents Yes No Yes No 2017-2018 Informed Consent Form It is critical that the planners of the STEP program collect information from students who participate in activities in order to continuously improve the program and meet students needs, as well as participate in focus group sessions to discuss the program. Participation in any of the information gathering activities is completely voluntary. Students may choose to omit items from surveys, choose not to complete surveys, or not to attend focus group sessions. Responses from individuals will not be reported in any form. All responses will be reported as a group to program planners in order to maintain anonymity. Your signatures below indicate that you understand the purpose and process described above, and you are willing to have your child participate in the STEP program gathering efforts. Choosing not to sign this consent from will in no way influence your child s ability to participate in the STEP program. Student Name (Print) Student Signature Date Parent/Guardian Signature Date STEP 2017-2018 Application for Print Page 3

Student Name: SYRACUSE UNIVERSITY 2017-2018 STEP Program Contracts & Agreements Grade 1. Saturday Learning Academy/ Enrichment Program Contract Student Responsibilities Maintain a minimum average of 75% in science and math courses. Maintain a minimum overall GPA of 75%. Arrive at STEP Session on time and ready to participate with applicable assignments/materials. Conduct yourself in a manner conducive to your own learning, and to the learning of others. Respect the STEP Staff, workshop coordinators, and other students in the program. When necessary, come to tutorials with applicable textbooks and classroom assignments. Agree to adhere to the student absence and tardiness procedures, and the Anti-Bullying Pledge. Parent/ Legal Guardian Responsibilities [Program hours are 10:00am 12:00pm; Enrichment is 12:15pm 1:45pm] Drop off and pick up students from the Life Sciences Building (111 College Place) on Saturday mornings at designated times. o Students may not be dropped off after 10:15am and must be picked up at 12:00pm if they are not staying for Enrichment. o Students who participate in Afternoon Enrichment must be picked up by 2:00pm. Make alternative transportation arrangements when you cannot pick up your student on time. Talk with students about STEP activities and expectations. Adhere to deadlines. Read ALL information pertaining to the program. Remind students to bring applicable assignments/materials to each session including tutorials. Participate in at least two open-to-parents/ family STEP activities per semester. 2. Press and Performance Release I hereby give my permission to Syracuse University, its agents, successor, assigns and/or newspapers, radio, television or websites, statewide conferences to use my child s photograph (whether still, motion or television) and recordings of my child s voice, for publicity regarding the STEP Program. Indication of Understanding By signing below, we certify that the STEP Scholar and Parent/Guardian named herein have read the 2017/2018 Saturday Learning Academy/ Enrichment Program Contract and the Press and Performance Release; and, that we understand them, and we agree to abide by them. Furthermore, we understand that failure to abide by responsibilities could result in dismissal from the program. Print Parent/ Legal Guardian Name Parent/ Legal Guardian Signature Date Print STEP Student Name STEP Student Signature Date STEP 2017-2018 Application for Print Page 4

2017-2018 Income Verification Page THIS PAGE IS ONLY REQUIRED IF YOU SELECTED YOUR ETHNICITY AS Native Hawaiian/ Pacific Islander, Asian (Excluding Pacific Islanders), White/Caucasian, or Other on page 1. Student Name: Grade Please enter the number of people who live in your household. This includes everyone living in your home who are dependent on the household income. Number of household members: Please enter your household s annual income from the previous year. This refers to all funds received for the support of the household in the previous calendar year. For this 2017/2018 application, provide household income from the 2015 calendar year. Household Annual Income: $ The income as indicated above MUST be documented by submitting one of the following: Signed copy of the IRS forms 1040, 1040A, or 1040EZ Copy of the IRS form 4506 filled by the applicant s family and returned by the IRS Documentation of other taxable or non-taxable income: o A letter is needed from one of the following applicable agencies showing total award for entire household. (Agencies include: Social Services, Social Security, and Pension Fund) Why do we need this information? Since the STEP Program is grant funded, we must prove the eligibility of students in the program who do not qualify because of their ethnicity. The Program guidelines require that the household size and household income fall within certain ranges as per below: Number of Household Members: Household Income must be at or below this amount to qualify: 1 $22,311 2 $30,044 3 $37,777 4 $45,510 5 $53,243 6 $60,976 7 $68,709 8 $76,442 For any additional household members, add $7,333 per person to calculate the maximum household income to qualify. STEP 2017-2018 Application for Print Page 5

2017-2018 STEP New Student Recommendation Form Only complete this page if you are NEW to the program! Please complete the brief questionnaire below for the STEP Applicant who has requested your recommendation for admission to STEP for the 2017/2018 Academic Year. Note: Persons recommending a student must be a member of the student s community or school. The following individuals are examples of those who may complete this form: Pastors, Teachers, Dance Instructors, Coaches, and/or Supervisor. Parent/Guardian CANNOT complete their child s recommendation. Applicant Name: School Name: Grade: District: Please compare this student to other students you may have a working relationship with: Top 2% Top 10% Top 25% Top 50% Less than 50% Maturity Positive interaction with peers Inquisitiveness Ability to complete tasks Student s Strengths: Student s Weaknesses: Additional Comments: I certify that the participant named above meets the selection criteria, as described on the following page, for the Science and Technology Entry Program (STEP) and has my recommendation for participation in the program. Person Recommending Participant: Position: Email Address: Telephone: Signature: Date: Completed recommendation forms should be submitted to Syracuse University s Science and Technology Entry Program (STEP) as soon as possible. Forms may be faxed directly to the STEP office at: 315-443-5683, sent as a PDF file to step@syr.edu, or returned directly to the student. STEP 2017-2018 Application for Print Page 6