Loudoun County Public Schools

Department of Pupil Services

21000 Education Court

Ashburn, Virginia20148

Telephone: 571-252-1017

FAX: 571-252-1245

CAMPUS Application Packetfor Upper Class Students

(2013 -2014)

CAMPUS invites interested upperclassmen to apply. CAMPUS, a Guidance Services initiative of Loudoun County Public Schools, is an academic and college preparation program beginning its eleventh year in the 2013-2014 school year. CAMPUS is designed to meet the specific needs of students from historically under-represented groups in higher education and prospective first-generation college students.

CAMPUS provides students with systematic and coordinated experiences to enhance academic success and college preparation. The program supports students through critical experiences that begin from the time students leave middle school until high school graduation. CAMPUS provides academic enrichment and support, self-advocacy skills development, college and university visits, college and scholarship preparation, leadership development, carefully guided course selection, community service opportunities, and meaningful co-curricular and extracurricular activities. Selected students will be expected to enroll in the CAMPUS class and/or attend mandatory meetings and participate in CAMPUS events and activities throughout their high school years.

Candidates should show promise for high school and college success, and will be selected based on a variety of factors including:

  • Potential aptitude for success in post-secondary education
  • Leadership potential
  • Demonstrated interest in learning
  • Teacher recommendations

Strong consideration will be given to those students who:

  • Will be first in their family to graduate from a college or university
  • Come from an historically under-represented group in higher education
  • Come from a single parent family
  • May be considered socio-economically disadvantaged

If you are interested in applying, please submit the enclosed application form, along with two teacher recommendations, to your School Counselor. All applications received will be reviewed by a selection committee, and students will be notified. If you have any questions, please contact Chris Clarke, CAMPUS Program Manager, at 571-252-1017.

CAMPUS Applicationfor Upper Class Students (2013-2014)

Please complete the application by printing clearly in ink or by typing. Additional pages may be attached. Please make sure your full name is written or typedon each page. All information is confidential and will only be shared with counselors and the selection committee. Please submit this application to your School Counselor.

Name:

First Middle Initial Last Preferred Nickname

Middle School:

Home Room Teacher: Counselor:

High School:

Home Address: Phone:

Email:

City: State: Zip:

Date of Birth: Sex:  M  F

Student ID:

Optional:With which ethnic group do you identify:  Asian  African American  Hispanic

 Native American  Caucasian  Other ______

Family Information

Information on adults with whom you reside:

Name of Father/Stepfather/Guardian:Name of Mother/Stepmother/Guardian:

Occupation: Occupation:

Employer: Employer:

Email: Email:

Highest Level of Education:(USA or Abroad)Highest Level of Education: (USA or Abroad)

years in High School years in High School

 High school diploma High school diploma

 GED GED

 2-Yr. college diploma (AA) 2-Yr. college diploma (AA)

 4-Yr. college diploma (BS/BA) 4-Yr. college diploma (BS/BA)

 Degrees beyond BS/BA or  Degrees beyond BS/BA or

Certifications Certifications

 Degrees Earned outside US (School Attended) Degrees Earned outside US (School Attended)

Optional:

Is your child eligible for free or reduced school lunch? Yes No

Does your family receive public assistance? Yes No

Does your family reside in federally subsidized housing? Yes No

Please list any languages other than English spoken at home:

Student’s Name:

Student Personal Responses

Please provide thorough answers to the following questions in the space provided on this sheet. Your responses are an important part of the application and will be reviewed by the Selection Committee.

1.List your activities in your community and school and why they are important to you. Examples can include activities in church, your community, youth groups, and your school. You may also include responsibilities for helping others in your neighborhood, your family, and your school. Also, list any leadership positions you have held.

  1. Describe a special challenge you have had and how you overcame it.
  1. What are your goals after high school graduation?
  1. Why is it important for you to be a part of CAMPUS?

Student’s Name:

Student Checklist

 I have completed all sections of the CAMPUS application.

 I have answered the Student Personal Responses.

 I have included two completed teacher recommendation forms.

 I have discussed CAMPUS with my parent/guardian(s) and obtained their signature.

I understand that if I am selected as a CAMPUS 9th grader, I will be expected to enroll in the CAMPUS class and/or CAMPUS meeting at my high school and participate in all mandatory CAMPUS events. I understand and I am willing to make this commitment.

Student SignatureDate

Parent/Guardian Section

Your son or daughter is applying to participate in CAMPUS, a Loudoun County Public Schools’ guidance program designed to enhance academic and college preparation. Any questions about the program may be directed to Chris ClarkeCAMPUS Program Managerfor Loudoun County Public Schools. Parent/Guardian support and involvement are critical to the success of your child and the program.

Please feel free to use the space below to provide the selection committee with information about your child’s unique characteristics that make him/her a good candidate for CAMPUS.

Your signature below indicates that you are supportive of your child’s application and participation in CAMPUS if selected. You also agree to participate in CAMPUS parent/guardian involvement activities and events.

Parent/Guardian SignatureDate

Parent Comments:

Student’s Name

Teacher Recommendation for CAMPUS#1

Student’s Name:

Student’s Counselor:

Teacher’s Name:

Subject you teach the applicant:

Please return this form to your school counselor.

The student named above is applying to participate in CAMPUS,a Loudoun County Public Schools’ Guidance Services initiative. CAMPUS will provide students with systematic and coordinated experiences to enhance academic and college preparation. CAMPUS is designed to meet the specific needs of students from under-represented populations in higher education and prospectivefirst-generation college students.

The program seeks to identify students who have the ability to succeed academically in high school and college. Students should read on or above grade level. Some of the students may be role models, and others may need support and nurturing. Students should demonstrate respectful behavior towards peers and staff members.

Your responses to the questions below will be added to the student application, writing sample, scholastic record, and parent/guardian comments and will be reviewed by the selection committee.

Please place a check in the appropriate box below to rate the student from 1-5 on the following:

1
Among top 5% of students I’ve taught / 2
outstanding / 3
good / 4
fair / 5
weak
  1. Academic Potential, “Spark”

  1. Desire to learn

  1. Desire to excel

  1. Citizenship

  1. Leadership potential

  1. Relationships with peers

  1. Relationships with adults

  1. Seeks help when needed

Please attach a statement commenting on this student’s strengths and weakness, as well any situations where the student has thrived with positive adult attention, assistance, and/or reinforcement. Feel free to provide any other information which will be helpful for the selection committee to know.

Thank you for your support and assistance.

Student’s Name:

Teacher Recommendation for CAMPUS#2

Student’s Name:

Student’s Counselor:

Teacher’s Name:

Subject you teach the applicant:

Please return this form to your school counselor.

The student named above is applying to participate in CAMPUS,a Loudoun County Public Schools’ Guidance Services initiative. CAMPUS will provide students with systematic and coordinated experiences to enhance academic and college preparation. CAMPUS is designed to meet the specific needs of students from under-represented populations in higher education and prospectivefirst-generation college students.

The program seeks to identify students who have the ability to succeed academically in high school and college. Students should read on or above grade level. Some of the students may be role models, and others may need support and nurturing. Students should demonstrate respectful behavior towards peers and staff members.

Your responses to the questions below will be added to the student application, writing sample, scholastic record, and parent/guardian comments and will be reviewed by the selection committee.

Please place a check in the appropriate box below to rate the student from 1-5 on the following:

1
Among top 5% of students I’ve taught / 2
outstanding / 3
good / 4
fair / 5
weak
1. Academic Potential,
“Spark”
2. Desire to learn
  1. Desire to excel

  1. Citizenship

  1. Leadership potential

  1. Relationships with peers

  1. Relationships with adults

  1. Seeks help when needed

Please attach a statement commenting on this student’s strengths and weakness, as well any situations where the student has thrived with positive adult attention, assistance, and/or reinforcement. Feel free to provide any other information which will be helpful for the selection committee to know.

Thank you for your support and assistance.

Rising 9th Grade CAMPUS Student

Contact Information Form

2013/2014

Student first & last name:
High school he/she will attend:
Student cell phone number:
Student primary email address:
Name of Father/Stepfather/Guardian:
Name of Mother/Stepmother/Guardian:
Father/Stepfather/Guardian cell phone number:
Mother/Stepmother/Guardian cell phone number:
Father/Stepfather/Guardian email address:
Mother/Stepmother/Guardian email address:
Home phone number:

Note: This page must be TYPED. This page will be kept strictly confidential.