Achieve at Noble and Greenough School Application for Current 6 th Grade Students PART 1: Student Information Priority Deadline: February 10, 2017 Final Deadline: March 3, 2017 Student Name: Date of Birth: Age: First Middle Last MM/DD/YYYY Home Address: Number Street Apartment Male Female City State Zip Home Phone: ( ) - Email Address: Place of Birth: Country of Birth (if student was born outside the U.S.): City, State If born outside the U.S., how many years has the student lived in the U.S.? Does the student speak a language other than English fluently? If so, what language? How did you learn about applying to Achieve? Friend/Relative Community Center Achieve Website Teacher/Counselor Presentation at my school Other (specify): *** Current School: Current Grade: School Address: Main Telephone ( ) - Grades Attended Principal s Name: Guidance Counselor s Name: What school will the student attend in 7th grade? Has the student ever repeated a grade? If yes, what grade and why? Student s Ethnic Background/Race (optional):
PART 2: Parent/Family Information African American/Black Asian/Pacific Islander White Latino/Hispanic Native American Other: Check One: Parent 1: Relationship to Student Legal Guardian Check One: Parent 2: Relationship to student Legal Guardian Full Name: Full Name: First Last First Last Home Address: Home Address: Number Street Apartment Number Street Apartment City State Zip City State Zip ( ) - cell ( ) - work ( ) - ( ) - Home Phone Alternate Phone Home Phone Alternate Phone cell work Email Address: Email Address: Occupation Employer Occupation Employer Work Address Work Address Country of Birth Ethnicity/Nationality Country of Birth Ethnicity/Nationality Native Language: Native Language: Highest Level of Education: Highest Level of Education: Achieve collects the following information to report to funders it allows us to offer our program for free. Incomplete applications will not be considered. Check one answer for each question. 1. What is the highest level of education achieved by a parent or guardian of the applicant? Middle school or before Some high school High school graduate Some college College graduate 2. Are any of your child s older siblings CURRENTLY attending college? Yes No 3. Have any of your child s older siblings GRADUATED from college? Yes No 4. Is a language other than English spoken at home? Yes No If yes, please specify the language spoken at home, using the choices below. Arabic Chinese/Mandarin/Cantonese Korean Russian Spanish Albanian Vietnamese Other (specify): 5. With whom does the student live? Both Parents/Guardians Single Parent (check one): Mother/Female Guardian Father/Male Guardian 6. Status of Student s Parents (Check all that apply): Married Separated Divorced Single Parent Mother Deceased Father Deceased 7. Number of siblings Ages:
PART 3: Income Verification 8. Does the student currently have an IEP at School? Yes No 9. Is any relative or friend of the student enrolled in or applying to Achieve? Please indicate their name(s) and relationship to student: Achieve is committed to serving low-income students who are enrolled in Boston Public Schools. All families must submit proof of income in order to be considered for admission to Achieve. No application will be considered without this information and all information will be kept completely confidential. Parent(s)/Guardian(s) must submit the following documents for income verification: o Copy of 1040 and W-2 forms for 2015 for household To be eligible for Achieve, family income must be at or below the following levels: Family of 2: $26,000 Family of 3: $35,000 Family of 4: $40,000 Family of 5: $50,000 Family of 6 or more: $65,000 PART 4: Family Commitment Achieve holds its scholars to high standards, both behaviorally and academically. We expect our scholars to be in attendance at both summer and Saturday sessions with a positive attitude and a willingness to learn. Please initial each item and sign below to acknowledge that BOTH the student and the parent/guardian understand the family commitment. STUDENT Initials below: I am excited and committed to attending Achieve everyday for five and a half weeks this summer. I will maintain a positive attitude and know that disruptive and inappropriate behavior is not tolerated. I will complete all class assignments and homework as required. PARENT/GUARDIAN Initials below: I will ensure that my child does not miss any days of Achieve. I understand that 3 unexcused absences may result in dismissal from Achieve. I will ensure regular and on-time student attendance. Please explain any schedule conflicts (or write none ): (Program dates: Mondays Fridays, closed July 4th) Parent/Guardian Signature: Date: Student Name: Student Signature:
PART 5: Student Statement TO THE STUDENT: Please write a response in the space provided for each of the following short answers/essays. Type or hand-write your responses legibly in BLUE or BLACK ink. Return To: Achieve 10 Campus Drive Dedham, MA 02026 Student s Name Student s School 1. What is your favorite subject in school? What do you like about the subject? 2. What is your weakest subject in school? What is difficult for you in this class? 3. Describe a situation in which you displayed your leadership abilities.
4. Describe a situation during which you wish you had behaved differently or made different choices. Why did you choose to do what you did? If you could relive the experience, what would you do differently? 5. What do you hope to gain from attending the Achieve program? Why do you think we should choose you to be in the program? 6. Please CIRCLE FIVE words that you would use to describe yourself. Smart Cheerful Confident Cooperative Distracted Immature Creative Curious Focused Genuine Irritable Quiet Independent Funny Mature Patient Self-centered Shy Lazy Dependable Athletic Lonely Happy Energetic Impatient Loud Negative Confused Hard-working Sad Student Certification I, certify that the Student Statement section of the Achieve Application for Admission Student s Name has been written by me and reflects my authentic and original ideas and experiences. Student s Signature
PART 6: Parent/Guardian Statement TO PARENT/GUARDIAN: Please respond to the questions below in BLUE or BLACK ink. You may also type your answers. Return To: Achieve 10 Campus Drive Dedham, MA 02026 Student s Name Student s School 1. What THREE words would you use to describe your child? 2. What do you consider to be your child s personal and academic strengths and weaknesses? 3. What is your child s attitude toward education? Please comment on your child s study habits. 4. What do you hope Achieve will do for your child if he/she is accepted into the program?
5. Achieve believes that parental involvement is crucial to a child s educational success. We require a commitment from parents/guardians, as well as the students. We ask that parents/guardians take responsibility for their child s consistent attendance. Would you be able to make this kind of commitment? If not, please explain. 6. If your child is accepted into the program and decides to enroll, you will need to plan family events and vacations around the dates listed below. Except in the case of illness, attendance is mandatory. Summer 2017: June 24 - August 1 Academic Year 2017-2018: Two Saturdays per month Summer 2018: Last week of June through first week of August Academic Year 2018-2019: Two Saturdays per month Summer 2019: Last week of June through first week of August Do you see any possible conflicts with the dates listed above (Summer or Saturdays)? No Yes If yes, please describe the conflicts here: 7. Does your child participate in any other programs or activities? (i.e. Boys and Girls Club, sports, music, etc.) 8. Is your child applying to any other summer programs? 9. Is there anything else we should know about your child? Parent/Guardian s Signature Parent/Guardian s Signature
PART 7A: Teacher Reference (English or Math only) TO THE TEACHER: The student named below is applying to Achieve - a rigorous tuition-free academic enrichment program. Achieve seeks motivated, talented students to participate in our multi-year program, which is comprised of three six-week summer sessions and Saturday sessions during the academic year. Achieve is committed to serving low-income middle school students who would thrive in a community where academic and social standards are high. Above all, Achieve seeks students who will commit to attending all sessions and who will work hard! We appreciate your candid responses and thank you for your help in this process. PLEASE NOTE: THIS REFERENCE WILL BE KEPT CONFIDENTIAL AND SHOULD BE SUBMITTED DIRECTLY TO ACHIEVE BY THE TEACHER. REFERENCES SUBMITTED BY APPLICANTS WILL NOT BE ACCEPTED. Return To: Achieve 10 Campus Drive Dedham, MA 02026 Student s Name Student s School Teacher s Name Subject(s) 1. Please describe this student s academic performance, conduct, and effort in your class. 2. Does the student have difficulty grasping new concepts and retaining information? Does he/she seek help when needed? 3. Do the student s grades truly reflect his/her academic ability? If not, where is the disconnect between the student s grades and ability? 4. The Achieve program is a very rigorous academic environment. How do you think this student will respond to high academic and behavioral standards? 5. How could Achieve benefit this student? If accepted, what might this student contribute to the program?
Please circle the response that best suits the student in relation to the other students you teach. Outstanding (Top 10%) Excellent Good Poor Not applicable a. Academic motivation 4 3 2 1 N/A b. Attitude towards homework 4 3 2 1 N/A c. Study skills 4 3 2 1 N/A d. Writing skills 4 3 2 1 N/A e. Math skills 4 3 2 1 N/A f. Intellectual curiosity 4 3 2 1 N/A g. Willingness to try new activities 4 3 2 1 N/A h. Time management 4 3 2 1 N/A i. Ability to be a group leader 4 3 2 1 N/A j. Class participation 4 3 2 1 N/A k. Enthusiasm for class projects 4 3 2 1 N/A l. Ability to work independently 4 3 2 1 N/A m. Self-confidence 4 3 2 1 N/A n. Ability to accept criticism 4 3 2 1 N/A o. Contribution to positive spirit in your classroom 4 3 2 1 N/A p. General level of maturity 4 3 2 1 N/A q. Organization skills 4 3 2 1 N/A r. Ability to interact with adults 4 3 2 1 N/A I recommend this student to the Achieve program: With great enthusiasm With confidence With some confidence* With reservation* I do not recommend* If any of the above options with an asterisk (*) were selected, please explain:
PART 7B: Additional Teacher Reference (recommended) Teacher s Name Teacher s Signature Phone Number ( ) - Email: TO THE TEACHER: The student named below is applying to Achieve - a rigorous tuition-free academic enrichment program. Achieve seeks motivated, talented students to participate in our multi-year program, which is comprised of three six-week summer sessions and Saturday sessions during the academic year. Achieve is committed to serving low-income middle school students who would thrive in a community where academic and social standards are high. Above all, Achieve seeks students who will commit to attending all sessions and who will work hard! We appreciate your candid responses and thank you for your help in this process. PLEASE NOTE: THIS REFERENCE WILL BE KEPT CONFIDENTIAL AND SHOULD BE SUBMITTED DIRECTLY TO ACHIEVE BY THE TEACHER. REFERENCES SUBMITTED BY APPLICANTS WILL NOT BE ACCEPTED. Return To: Achieve 10 Campus Drive Dedham, MA 02026 Student s Name Student s School Teacher s Name Subject(s) 1. Please describe this student s academic performance, conduct, and effort in your class. 2. Does the student have difficulty grasping new concepts and retaining information? Does he/she seek help when needed? 3. Do the student s grades truly reflect his/her academic ability? If not, where is the disconnect between the student s grades and ability? 4. The Achieve program is a very rigorous academic environment. How do you think this student will respond to high academic and behavioral standards? 5. How could Achieve benefit this student? If accepted, what might this student contribute to the program?
Please circle the response that best suits the student in relation to the other students you teach. Outstanding (Top 10%) Excellent Good Poor Not applicable a. Academic motivation 4 3 2 1 N/A b. Attitude towards homework 4 3 2 1 N/A c. Study skills 4 3 2 1 N/A d. Writing skills 4 3 2 1 N/A e. Math skills 4 3 2 1 N/A f. Intellectual curiosity 4 3 2 1 N/A g. Willingness to try new activities 4 3 2 1 N/A h. Time management 4 3 2 1 N/A i. Ability to be a group leader 4 3 2 1 N/A j. Class participation 4 3 2 1 N/A k. Enthusiasm for class projects 4 3 2 1 N/A l. Ability to work independently 4 3 2 1 N/A m. Self-confidence 4 3 2 1 N/A n. Ability to accept criticism 4 3 2 1 N/A o. Contribution to positive spirit in your classroom 4 3 2 1 N/A p. General level of maturity 4 3 2 1 N/A q. Organization skills 4 3 2 1 N/A r. Ability to interact with adults 4 3 2 1 N/A I recommend this student to the Achieve program: With great enthusiasm With confidence With some confidence* With reservation* I do not recommend* If any of the above options with an asterisk (*) were selected, please explain: Teacher s Name Teacher s Signature
PART 8: Release Form Phone Number ( ) - Email: Return To: Achieve 10 Campus Drive Dedham, MA 02026 (781) 320-1329 fax Student s Name Student s School TO THE PRINCIPAL/COUNSELOR/TEACHER: The student named above is applying to Achieve - a rigorous tuition-free academic enrichment program. Achieve seeks motivated, talented students to participate in our multiyear program, which is comprised of three six-week summer sessions and Saturday sessions during the academic year. Achieve is committed to serving low-income middle school students who would thrive in a community where academic and social standards are high. Above all, Achieve seeks students who will commit to attending all sessions and who will work hard! Please attach complete transcripts including: o Report card grades for 5 th and 6 th grade o Standardized test scores o Attendance records NOTE: THIS INFORMATION WILL BE KEPT CONFIDENTIAL AND SHOULD BE SUBMITTED DIRECTLY TO ACHIEVE BY A SCHOOL OFFICIAL. TRANSCRIPTS SUBMITTED BY APPLICANTS WILL NOT BE ACCEPTED. If you have any questions regarding the program, please feel free to contact the Achieve office. TO BE COMPLETED BY PARENT/GUARDIAN: CONSENT TO RELEASE ACADEMIC INFORMATION In order to assist the Achieve staff in developing a clear view of my child s academic ability and social progress in school, I hereby authorize the release of complete school records and transcripts for my child,, Student s Name to Achieve at Noble and Greenough School. Thank you. Parent/Guardian s Signature Date