Applicant S (Legal) Name

/
Douglas County Performance Learning Center
2300 Shoals School Road
Douglasville, Georgia 30135
(770) 651-6475 Telephone (770) 651-6488 Fax

Application for Admission

Applicant’s (Legal) Name

Last First (Indicate preferred name in CAPS) Middle

Street Address

City

State

Zip

Is this your mailing address? / Yes / No / If no, please specify:

Home Phone

/ ( ) / Parent’s Cell Phone ( )

Area Code Area Code

STUDENT BIOGRAPHICAL INFORMATION

Date of Birth

/ Age / Gender
Female
Male

Place of Birth

CityStateCountry

Ethnicity

Asian or Pacific Islander / American Indian/Alaskan Native / Black (non-Hispanic)
Hispanic (including Puerto Rico) / White, Anglo, Caucasian / Other

(specify)

Student resides with:

Both Parents / Guardian /

Specify Relationship

Father / Group Home / Please Specify
Mother / Name of Home Contact Name
( )

Contact PhoneArea Code

Have you ever attended the PerformanceLearningCenter? / Yes / No / If yes, grades and years attended
Have you ever applied for admission to the PerformanceLearningCenter? / Yes / No / If yes, year
Current School:
Last Grade Completed:

PARENT/GUARDIAN INFORMATION

Mr. & Mrs. / Mr. / Ms. / Other______
Parent/Guardian 1:
Employer: / Work Phone: / ( )
Email Address:
Parent/Guardian 2:
Employer: / Work Phone: / ( )
Email Address:
Emergency Contact / Relationship to student: / Emergency phone:
( )

ADDITIONAL BIOGRAPHICAL INFORMATION

Number of adults in household:

Number of children in household:

Is the student a parent? / Yes
No /

Age of child

Does the student work? / Yes
No

Hours worked weekly

Address:
Phone:

Applicant’s Curricular and Extracurricular Interests

What subject(s) do you consider your strengths?
In what subject(s) have you had the most difficulty?
What colleges are you interested in attending?
What profession(s) or vocation(s) are you considering?
What previous honors or academic awards have you received?
List the organizations and offices in which you have been involved.
What are your other interests:
If you are accepted into the PLC, you will be required to participate in community services activities. Would you be willing to participate? / Yes / No

Due to NCAA regulations established August 1, 2010, some non-traditional courses may not meet the requirements for initial NCAA eligibility. Courses completed online meet graduation requirements in Georgia, but may not meet requirements set forth by the NCAA. This may impact a student’s eligibility status during their first year in college. Parents or students needing confirmation that an online course meets the NCAA eligibility requirements should obtain confirmation in writing from the school counselor.

X

Student Signature

X

Date

Parent /Guardian Signature Date

STUDENT NAME: GRADE: DATE: __

REFERRED BY (Name/Position): PHONE:

STUDENT’S TRANSCRIPT AND DISCIPLINARY TRACKING RECORDS MUST ACCOMPANY THIS REFERRAL FORM. PLEASE ATTACH TO FORM.

PRIMARY REASON FOR REFERRAL TO PERFORMANCELEARNINGCENTER:

Academic Failure – not enough Carnegie Units

Excessive Absenteeism - absences impeding child’s education

 Excessive Tardiness - late to class

Apathy/Indifference to Education – no interest in school

 Social Issues: student exhibits poor self-esteem/does not interact well with peers.

 Other (please specify):______

PLEASE CHECK ANY FACTORS OR CHARACTERISTICS LISTED BELOW WHICH APPLY TO STUDENT

POOR ACADEMIC ACHIEVEMENT

 Retained (held back) one or more years

 Grades are well below potential of student

Failed 2 or more subjects in recent semester

 Student in need of remediation

 Other (please specify): ______

EXCESSIVE UNEXCUSED ABSENCES/TARDINESS/SKIPPING CLASSES

Absent _____ days last year/semester/marking period (please circle time period)

Late to school _____ days last year/semester/marking period (please circle time period)

Student skipped _____ classes last year/semester/marking period (please circle time period)

Other (please specify): ______

3. APATHY/INDIFFERENCE TO EDUCATION

Little/No Interest in School

Student Needs to be Challenged/Student Bored

Student Does not Fit In at School

Other (please specify): ______

4. SOCIAL ISSUES

 Low Self Esteem

 Does not interact well with peers

Student does not interact well with teachers/school administration

Other (please specify): ______

To Applicant:

Please Print or type this section and deliver this form to your guidance counselor, administrator, or teacher. The Evaluator will mail these forms directly to Communities In Schools Performance Learning Center.

Applicant’s Name

Grade

LastFirstMiddle (Current)

Street Address

City

State

Zip

Date ______/

Date

/ Parent Signature

Student Signature

-TO BE COMPLETED BY EVALUATOR-

To Evaluator:

The student named above has made application for admission to Communities In Schools Performance Learning Center. Please complete this form and mail it and the information indicated in the self-addressed envelope provided. The information will not be included in the student’s permanent file. Please confer with professional colleagues to ascertain information, if necessary. Thank you.

Evaluator’s Name
Title
School
Street Address
City / State / Zip
Telephone / ( )

Area Code

How long have you known the student? ______
Do any of the following apply for this student:
ESL
Learning disability
Other exceptionality
Please specify: ______
To your knowledge has the student had any history of serious conduct problems? / Yes / No
If yes, please explain. ______
______
Has the applicant ever been expelled or suspended? / Yes / No

If yes, please explain ______

______

Please comment on the applicant’s attitude toward school.______
______
______
To your knowledge, has the applicant had any involvement with drugs or alcohol? / Yes / No
Describe the student’s strengths. ______
______
To your knowledge, will the applicant take good advantage of the curricular and extracurricular activities offered by the PLC? ______
______

Please complete the appropriate blanks. As with the above questions, you may desire to confer with colleagues to make your recommendation.

Below
Average / Average / Good / Excellent / Outstanding / No Basis
for Judgment
Motivation
Creative Qualities
Self-Discipline
Growth Potential
Leadership
Self-Confidence
Personal Appearance
Warmth of Personality
Sense of Humor
Concern for Others
Energy
Emotional Maturity
Personal Initiative
Reaction to Setbacks
Physical Condition
Respect for Authority
School Conduct
Out of School Conduct
Additional Comments: ______
______
______
______

Please feel free to attach a letter of recommendation or any other pertinent documents.

Evaluator’s Signature ______
Date ______

To Applicant:Please Print or type this section and deliver this form to your guidance counselor, administrator, or teacher. The Evaluator will mail these forms directly to Communities In Schools Performance Learning Center.

Applicant’s Name

Grade

LastFirstMiddle (Current)

Street Address

City

State

Zip

Date ______/

Date

/ Parent Signature

Student Signature

-TO BE COMPLETED BY EVALUATOR-

To Evaluator:

Evaluator’s Name
Title
School
Street Address
City / State / Zip
Telephone / ( )

Area Code

If yes, please explain ______

______

Please complete the appropriate blanks. As with the above questions, you may desire to confer with colleagues to make your recommendation.

Below
Average / Average / Good / Excellent / Outstanding / No Basis
for Judgement
Motivation
Creative Qualities
Self-Discipline
Growth Potential
Leadership
Self-Confidence
Personal Appearance
Warmth of Personality
Sense of Humor
Concern for Others
Energy
Emotional Maturity
Personal Initiative
Reaction to Setbacks
Physical Condition
Respect for Authority
School Conduct
Out of School Conduct
Additional Comments: ______
______
______
______

Please feel free to attach a letter of recommendation or any other pertinent documents.

Evaluator’s Signature ______
Date ______

Why do you wish to attend the Douglas County Performance Learning Center? What do you hope to give to and get out of this experience?

Please check all that apply:

□Adjudicated youth□ Child of active duty military

□Credit recover/retrieval□ Eligible for free/reduced lunch

□English Language Learner/Limited Eng. Proficient□Foster care/group home

□Gang involvement□Homeless

□Incarcerated parent□Special Education

□Pregnant/ Parenting□ Aggressive behavior

□Substance abuse□ Excessive after school work hours

□ High risk behavior (alcohol, drugs)□ Lack of effort

□ Low commitment to school□ Misbehavior

□ Overage for grade□ Poor attendance

□ Retained in grade□ Emotional disturbance

□ Excessive social activity outside of school□ Learning disability

□ Low educational expectations□ No extracurricular activity

□Poor academic performance□ High family mobility

□ Family Disruption□ Large number of siblings

□ Sibling has dropped out of school□ not living with natural parents

Complete Application Includes the following items:

___ Application for admission

___ Current transcript

___ High school discipline report

___ High school attendance report

Please submit all application materials to the graduation coach or counselor at the base high school.

Applicant S (Legal) Name

Application for Admission

Applicant’s (Legal) Name

Street Address

City

State

Zip

Home Phone

STUDENT BIOGRAPHICAL INFORMATION

Date of Birth

Place of Birth

Specify Relationship

PARENT/GUARDIAN INFORMATION

Number of adults in household:

Number of children in household:

Age of child

Hours worked weekly

X

X

Date

STUDENT NAME: ______GRADE: ______DATE: ______

REFERRED BY (Name/Position): ______PHONE: ______

PLEASE CHECK ANY FACTORS OR CHARACTERISTICS LISTED BELOW WHICH APPLY TO STUDENT

Applicant’s Name

Grade

Street Address

City

State

Zip

Date

Grade

State

Zip

Date

STUDENT NAME: GRADE: DATE: __

REFERRED BY (Name/Position): PHONE: