P.O. Box 26170 Greensboro, NC 27402 beyondacademics.uncg.edu Application Deadlines Fall 2015 Priority Consideration Deadline: November 3 rd, 2014 Fall 2015 Final Deadline: December 15 th, 2014 Application Checklist $55 application fee (non refundable). Please make check or money order payable to Beyond Academics at UNCG. Include your full legal name on your check. Applications received without the application fee enclosed will not be processed. Recent Psychological Evaluation conducted within three years, and/or other documentation with diagnostic information. Most current Person Centered Plan within one year (if applicable). If receiving services from another agency, and you want to give consent for Beyond Academics to contact them, please include the AUTHORIZATION TO RECEIVE HEALTH INFORMATION. You may download this form from our website http://beyondacademics.uncg.edu/admissions/. Most recent Individualized Education Plan (IEP) Copy of high school diploma and/or certificate of completion, or equivalent. Transcripts from all secondary and post secondary educational institutions. Two letters of recommendation. Letters should be from non relatives (teachers, counselors, supervisors, or community engagement) who know the student s level of motivation and who have known the applicant at least one year. Recent photo or headshot of student. If you are a U.S. citizen born abroad, please provide proof of citizenship (such as copy U.S. passport, U.S. birth certificate, certificate of naturalization or certificate of citizenship). If you are not a U.S. citizen, please provide one of the following: Permanent Resident (copy of Permanent Residency Card I 551) Permanent Residency Applicant (copies of Notice of Actions I485 and approved I 130 or I 140) Refugee or asylee (copy of Refugee/Asylee documents or I 94) Beyond Academics TM Student Application Page 1 of 12
Application Process All completed applications received by November 3 rd will be considered priority. Completed applications received after November 3 rd will be considered on a rolling basis until December 15 th. Applications received after December 15 th will be considered on a space available basis. Benefits of priority consideration: o Notification of missing application items before final deadline o Early acceptance notification Acceptance notification for priority applications: January 2015. Acceptance notification for all applications: March 2015. Applications are filed in the order in which they are received and reviewed by the Beyond Academics Admissions Committee throughout the year for fall enrollment. * Applying too close to the final deadline is strongly discouraged. Personal interviews are held by the Beyond Academics Admissions Committee with the prospective student and his/her parents or legal guardian. If accepted, the student begins the admissions/enrollment process with UNCG, with support from Beyond Academics during summer orientation. Prospective student applicants must meet the following criteria to be considered for admission: Have a documented diagnosis of an intellectual and developmental disability as defined by the American Association on Intellectual and Developmental Disabilities. Have concluded secondary education with a diploma, certificate of completion or equivalent. Be at least 18 years old before August 31 st of the academic year. Be able to live in student housing during non service hours. Have basic safety skills in unsupervised settings. Have support from family and a personal desire to gain necessary skills for self determination, independent living and employment. You may complete the application electronically and print to submit, or print and complete with black ink. Please Use Certified Mail and Submit Completed Application Packet to: Beyond Academics at UNCG P.O. Box 26170 Greensboro, NC 27402 Please call the Beyond Academics office with any questions at (336) 334 3905 or email us at info@beyondacademics.org Beyond Academics TM Student Application Page 2 of 12
Student Information 1. Full legal name as it appears on your Social Security Card or Birth Certificate Last Name First Name Middle Name 2. Sex Female 3. Ethnic/Racial Origin (not required; for statistical purposes only; not a factor in the admission decision) Select one or more: Male 4. Are you a U.S Citizen? American Indian or Alaska Native Asian Black or African American * If not, please provide current status: Hispanic or Latino Native Hawaiian or Other Pacific Islander White Yes No 5. / / Date of Birth (month/day/year) Permanent Resident (Copy of Permanent Resident Card or Notice of Action required) Applied for Permanent Residency (Copy of Notice of Action required) Refugee/Asylee (Copy of refugee/asylee document required) None 6. Place of Birth (city, state or foreign country) 7. Permanent Address Since / (month/year) 8. Mailing Address (if different from above Since / (month/year) 9. ( ) ( ) Telephone Cell Phone Email Address 10. Previous Address Since / (month/year) 11. Have you ever resided in a state other than North Carolina? Yes No 12. Last Address Outside NC From / (month/year) Until / (month/year) Country Beyond Academics TM Student Application Page 3 of 12
Academic History 13. Highest Level of Completed Education No High School Some High School GED Diploma Certificate of Completion Course of Study / / High School Location From (month/year) To (month/year) Anticipated Graduation Year College or Post secondary Vocational Programs Have you taken any college courses? Yes No Please list all colleges or post secondary schools you have attended Name of School Dates Attended Credits Earned Family Information 14. Mother Name ( ) ( ) Telephone Cell Phone Email Address 15. Father Name ( ) ( ) Telephone Cell Phone Email Address 16. Do you have a legal guardian? Yes No Not Sure Relationship to Applicant Mother Father Other Name ( ) ( ) Telephone Cell Phone Email Address Beyond Academics TM Student Application Page 4 of 12
17. Emergency Contact Parent Guardian Other Name ( ) ( ) Telephone Cell Phone Email Address Health Information 18. Please list your current medications Name Dosage Purpose Name Dosage Purpose Name Dosage Purpose Other 19. Disability Diagnosis/Diagnoses (Please attach documentation) 20. Medical Diagnosis/Diagnoses (Please attach documentation) 21. Mental Health/Behavioral Diagnosis/Diagnoses (Please attach documentation) Beyond Academics TM Student Application Page 5 of 12
22. Please check all that apply for this student. If applicable, attach proper documentation for each item. History of psychotropic medication use (Please explain) Prior and/or current treatment for mental health issues, including outpatient therapy or inpatient treatment (Please explain) Psychiatric hospitalizations (Please explain) Family history of mental illness (Please explain) Suspension from school or work for behavioral concerns (Please explain) Medical treatment for seizure activity (Please explain) History of eating or sleep disturbances (Please explain) At risk of harming themself, others, or the environment (Please explain) 23. Other health and disability information 24. Do you need help managing your medication? Yes No If yes, please explain 25. Do you require attendant care? Yes No If yes, please explain Beyond Academics TM Student Application Page 6 of 12
Service Provider Information 26. Are you currently receiving Medicaid Waiver Services? Yes No If yes, which service(s)? Home/Community Support Personal Care Residential Respite Other How many hours per week do you receive these services? Provider Agency Name Provider Provider Contact Name Phone Email 27. Are you receiving Care Coordination/ Case Management services? Yes No Care Coordinator Name Phone Name of Agency Agency Email 28. Are you currently receiving support from Vocational Rehabilitation Services? Yes No Name of Local Office Name of Counselor Phone Email Student Centered Information The below questions should be answered by the potential student with assistance only if needed. 29. Why do you want to attend The University of North Carolina at Greensboro (UNCG)? 30. What do you want to learn if accepted at UNCG?? Beyond Academics TM Student Application Page 7 of 12
31. Do you have a preferred method for learning? 32. What academic support do you need in the classroom? 33. Have you ever or do you currently utilize assistive technology? Yes No If yes, please explain 34 What are your short term and long term educational and career goals? 35. What are your talents and strengths? What are you good at doing? 36. What is important to you? What really matters in your life? 37. What would you like to change about your life? Beyond Academics TM Student Application Page 8 of 12
38. What fears do you have about attending college? 39. Have you ever lived away from home? Yes No If yes, please explain. Did you enjoy the experience? 40. What extracurricular activities are you currently involved with? 41. Do you have a paid or volunteer job? Yes No If yes, where do you work or volunteer? For Parents or Legal Guardian to complete (if applicable) Relationship Parent Guardian Other 42. In what areas would you like to see growth for this student while at UNCG? (be specific) 1. 2. 3. Other Beyond Academics TM Student Application Page 9 of 12
43. How much supervision does the student need? Constant, s/he spends no time alone Frequent, s/he is supervised most of the time but can spend brief periods alone Occasional, s/he receives sporadic supervision but spends several consecutive hours alone 44. Is the student able to take his/her own medications? Yes, takes his/her own medications without reminders S/he needs reminders to do these things but can do them independently No, s/he is not able to take medications independently nor with reminders 45. Is this applicant able to perform personal care tasks including bathing, teeth brushing, combing hair, and dressing? Yes, s/he performs the above independently S/he needs reminders to do these things but can do them independently S/he is not able to perform: (check any that s/he is not able to perform) Bathing Teeth Brushing Combing Hair Washing Hair Dressing Toileting Other 46. Upon waking in the morning, if s/he found that they were the only person awake in their home, s/he would Leave the apartment without regard to safety Remain in the apartment and wait for someone to assist them Safely begin a daily routine Call someone to ask what to do next Other comments regarding safety and health Beyond Academics TM Student Application Page 10 of 12
47. How did you learn about Beyond Academics at The University of North Carolina at Greensboro? 48. If you are the student s primary caregiver, how have you prepared yourself for the differences between high school and college? (i.e. student privacy, student self determination, etc.) Campus Safety Questions (Required for all applicants) Your yes answer to one or more of the following questions will not necessarily preclude your being admitted. However, your failure to provide complete, accurate, and truthful information will be grounds to deny or withdraw your admission, or to dismiss you after enrollment. For the purpose of the following six questions, crime or criminal charge refers to any crime other than a traffic related misdemeanor or infraction. You must, however, include alcohol or drug offenses whether or not they are traffic related. a) Have you been convicted of a crime? Yes No b) Have you entered a plea of guilty, no contest, nolo contendere, or an Alford plea, or have you received a deferred prosecution or prayer for judgment continued, to a criminal charge? Yes No c) Have you otherwise accepted responsibility for the commission of a crime? Yes No d) Do you have any criminal charges pending against you? Yes No e) Have you ever been expelled, dismissed, suspended, placed on probation, or otherwise subject to any disciplinary sanction by any school, college, or university? Yes No f) If you have ever served in the military, did you receive any type of discharge other than an honorable discharge? Currently Serving Never Served Yes No Beyond Academics TM Student Application Page 11 of 12
If you answered yes to any of the six questions above, please explain the circumstances below Furthermore, you must promptly notify the Office of Undergraduate Admissions in writing of any criminal charge; any disposition of a criminal charge; any school, college, or university disciplinary action against you; or any type of military discharge (other than an honorable discharge) that occurs at any time after you submit this application. Failure to do so will be grounds to deny or withdraw your admission, or to dismiss you after enrollment. Application Agreement: I certify that the responses provided on my application are true and complete to the best of my knowledge, pursuant to reasonable inquiry where needed. I understand my failure to provide complete, accurate, and truthful information on this application will be grounds to deny or withdraw my admission, or dismiss me after enrollment. Further, it is my understanding that I shall not be considered for admission to the University until I have submitted all credentials. I also agree to inform the Office of Comprehensive Transition and Postsecondary Education in writing, of any change in my plans to attend the University, any change of address, any change of my Campus Safety Questions responses, or residency. I understand that if I do not enroll or discontinue my enrollment at UNCG at any time, I must submit a new application by the appropriate deadline and pay a new application fee. UNCG is authorized to use my image (still or motion photography) in its promotional materials. Please Sign and Date Completed Application Signature of Applicant Guardian Signature (if applicable) / / Date (month/day/year) / / Date (month/day/year) Beyond Academics TM Student Application Page 12 of 12