Page 1 of 3

Student Application

Due to the Elon Academy Office by Friday, January 26th 2018 with the Parent Application. We will use the phone number you provided and contact you upon receipt of both applications. If you do not hear from our office, we encourage you to call us to ensure that we have received your application. We also encourage you to make a copy of both applications to keep for your records.

Please Print:

Name: ______

FirstMiddleLast

Home Phone: ______Email: ______

Birth date: _____/ _____/ _____

Please list your gender: ______

Check OneRace(optional):_____ African-American/Black_____ Native American

_____ White_____ Bi-Racial/Multi-Racial _____ Asian/Pacific Islander _____ Hispanic/LatinX _____ Other ______

Religious Preference (optional): ______

Country of birth: ______

Name of school you attend: ______Grade: ______

What school did you attend before this school: ______

What language do you speak at home: ______
Please complete the following: (Use the back if you need more room. Or, you may write or type your answers on a separate sheet to attach.)

  1. Activities and Leadership

List the activities in which you have been involved in the last two years. Please also include leadership roles that you have in those activities:

School Activities:

Community Activities:

Volunteer Activities:

Work for pay:
2. About you:

Think about your favorite class at school this year and your least-favorite class at school this year. Below, name the classes and describe yourself as a learner in both classes.

Favorite class:

Least-favorite class:

  1. Goals and Plans

What are your long-term career goals?Why are you interested in this particular career?

What specific steps have you taken to achieve these goals?

  1. Interest in Elon Academy

Explain why you are interested in attending the Elon Academy. What special talents and/or skills can you can bring to the Academy?

  1. Other Information

Is there other information that you would like for us to know about you?

  1. Signature and Agreement

By signing the following application, I am acknowledging that I wish to be accepted into the Elon Academy. My signature indicates that if I am accepted into the Academy I will make the Elon Academy my number one priority. I understand that full participation in the program is essential to my student success and agree not to planvacations and other activities that conflict with the Elon Academy program. I will participate fully (i.e., attend all three, consecutive summer sessions and participate in once a month Saturday meetings and mentor meeting during the academic school year).

______

SignatureDate