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IVY PREP APPLICATION PACKET
Deadline
August 18, 2017
Application Deadline (Postmarked):August 18, 2017
Applications will be accepted by mail only.
ONLY completed applications will be reviewed.
For questions/concerns, please contact Carolyn Dixonat
r 404-259-0424
*Tocompleteapplication,please useTimesNewRomanorArialFont
Ivy Prep ApplicationForm
Ivy Prepisacollege preparation program for middle and highschool females(grades 6-12) designed by the Chi Tau Omega Chapter of Alpha Kappa Alpha Sorority, Inc. ® and adopted by Community C.A.R.E.S. Foundation, the nonprofit entity of Chi Tau Omega.The purpose of Ivy Prep is to cultivate andencouragelife-long learning by empoweringyoungpeople with the foundationalskills needed to besuccessful ina post-secondary environment.The program seeks to improve the social statureamong youthand to helpmaintaina progressive interestincollegelife.
ApplicantCriteria:
The program is opento middle and highschool females (grades6-12).
The applicantmustbe currently enrolled in public, charter or privateschool
The applicantmust submitallapplication forms(seeApplicationChecklist).
The applicantmust submita written personalstatement(250 words) which articulates why the studentdesires to be inIvy Prep; and what they will bring to theprogram; what they planto takefrom the program(must be typed in 12font anddouble-spaced).
The applicantmusthavea2.5 grade pointaverage(4.0scale).
The applicantmust submita$10Application Fee(non-refundable)asa check ormoney order with the application.No application will be reviewedwithout theApplicationFee.
Note:
If applicant is accepted, a$50 Membership Fee(annual)will be required.Membership Fees are $50 each year, thereafter.All students are expected to payaMembership Fee.
The$50MembershipFeewillcoversometravelexpensesforcollegevisits,speaker fees,costforACT/SATPrepteachers(Kaplan,PrincetonReview,etc.),activities, andotherfinancialneedsforthestudentsthroughoutthecourseoftheyear.
.
andacknowledge,
(Parent/Guardian) (Student)
understand, and agree to the conditionsof thisprogram in order tobecome a participant.
______
Student’sSignature Date
Parent’s/Guardian’s Signature Date
Ivy Prep Personal Information
PleasePrintor TypeStudentInformation Below:
LastFirstMI
Home Address
Home PhoneNumberAlternate Phone Number
CityStateZip
Name ofSchoolGrade
School District
Name of Homeroom Teacher (if applicable)
Homeroom TeacherPhoneNumber (if applicable)Email
Nameof Guidance Counselor
Guidance Counselor Phone NumberEmail
Parent/GuardianName
Parent/GuardianPhone NumberEmail
Ivy Prep Personal Information
(continued)
Race/Ethnicity:
Birth date:
GPA
List All Extracurricular Activities (School, Church, Community,etc.):
College Goals:
______
______
______
Career Goals:
______
______
______
Student’sSignatureDate
Parent’s/Guardian’s SignatureDate
Ivy Prep
Program Models, Rules/Regulations, and Agreement
Ivy Preppromotes thedevelopment of essential skills forcollege entrance, matriculation, graduation,and productiveadult citizenship.The followingfourModels will be implementedto facilitate college preparation for globalleadership:(1) AdvancedAcademicPreparation (2)Culturaland Global Diversity(3) LeadershipDevelopment (4) ScholarshipAwareness and Financial Literacy.To ensure thatparticipants willacquire maximum benefitsfromtheir experiences,it is imperative that each Ivy Prep member honor the following program rules and regulations as attested by the required signature below:
1.Followinstructionsas theyaregiven byanyadultwho isapartof Ivy Prep.
2.Adhere to the appropriate dress code as defined by the Ivy Prep Advisor.
3.Students must maintaina 2.5grade pointaverage as they matriculate throughmiddle andhigh school.
All students must submit official school transcripts at the end of every semester (December andMay).
4.Behaveina manner thatreflects favorably upontheCommunity C.A.R.E.S. Foundation, Inc.®, when attending Ivy Prepactivities.Students are expected to practice good behavior atall times.
5.Attend 6 out of 8 business meetings and 75 % of;workshops, community service projects, and other scheduled activities regularly.Students cannot be absentfrom more than one event per month without an appropriate excuse. Students may be removed from the program if too many meetings, and/or outside events are not attended.
6.Any studentwhois found witha juvenile/adult justice system record may be subject toimmediate terminationfromthe program.
7.Students mustbe enrolledat a public, charter, or private high school(grades6-12).Ifa student is placed in alternativeschool for behavior reasonshe/she maybe subjectforimmediate termination.
I,have read and understandall of theabove rulesand regulationsandagree to follow these outlined rules as an effort to explore all fourof the aforementioned Ivy Prep Models.
I,understand thatifIamfound to be in violation ofany of the rulesandregulations, or code of ethics of the Ivy Prep program that the Community C.A.R.E.S. Foundation Inc. ® has theauthority to terminate my participation.
Ivy Prep
Program Models, Rules/Regulations, and Agreement
(continued)
We understand what the consequence(s)willbe shoulda violation of rulesand regulations occur.
Student’s Printed NameParent’s/Guardian’s Printed Name
Student’s Signature/DateParent’s/Guardian’s Signature/Date
Ivy Prep
Parental Consent/Permission Slip
I hereby request and consent that my childorward be permitted to participatein the IvyPrep Program.Ifurther understand that thisprogramisfor college preparation and that my childor ward may beaccompaniedandtransported to andfrom designatedevents, photographed, and/ or mentored, bya member of Community C.A.R.E.S Foundation, Inc.® oritsdesignee associated with this program.Bysigning below, I release The Chi TauOmega Chapter ofAlpha Kappa AlphaSorority, Incorporated and Community C.A.R.E.S. Foundation Inc.®,its membersand other volunteersassociatedwith this programfromany liability orinjury, loss, ordamage connectedinany way whatsoever with participation in this program.
I understandandagree to pay the required $10 Application Fee.Additionally, I will be responsible for theannual$50Membershipfee duefor eachacademicyear that my child or ward participatesinIvy Prep(otherarrangements may be made for parents on payment plans). Membership fees must be paid in full within thirty days– no exceptions.
Parent’s/ Guardian’s Name(Print)Date
Parent’s/Guardian’s SignatureDate
Ivy Prep
Media Release/Permission Slip
As you may be aware, ChiTauOmega Chapter and Community C.A.R.E.S Foundation Inc.® maintain websites and social media sitesthatcontain informationaboutserviceprojectsand programs.From time to time, we may videotape or photograph serviceprojects and programs.For the name(s), photo(s) or video(s) of someone under the age of18 to appear onourwebpage, or in other media broadcastssuchascommunity newspapersand magazines, we must obtainwritten permission.
I,give permissionfor my child or ward’sname, picture, videography, or work to appear in televisionbroadcasts, newspapers, magazines, journals,and/or onthe Community C.A.R.E.S Foundation Inc.® or the Chi TauOmega Chapter’s websites or social media. Iunderstand thatinformation broadcastson television and/or published on eitherwebsite may beaccessed by the general publicatany time.
Signing below affirms that both the student and parent/guardianunderstand the information listed above intheMediaRelease/PermissionSlip.Signingbelowalso confirms thatthe parent/guardian permits the student to beapartofanynews stories by traditionaland newmedia literacies.
Student’s Printed NameParent’s/Guardian’s Printed Name
Student’s Signature/DateParent’s/Guardian’s Signature/Date
Ivy Prep
Medical Release/Permission Slip
Student/ApplicantName (Print):
LastFirstMI Student D.O.B. Date of Most Recent Exam
Physician’s Name
Physician’s Address
Physician’s Phone NumberPhysician’s Email Address Primary Insurance Company
Subscriber’sName ______D.O.B. ______
Policy #Group # Student ______Relationship to Subscriber ______
Listany medical illnesses, injuries,or conditions that thestudent/applicant is currently experiencing:
Listall medications that the student/applicantis currently taking:
Emergency Contact Information:
All medical informationlisted above shall remainprivate unlessa studentis in medical danger.
Ivy Prep
Medical Release/Permission Slip
Student/ApplicantName (Print):
LastFirstMI Student D.O.B. Date of Most Recent Exam
Physician’s Name
Physician’s Address
Physician’s Phone NumberPhysician’s Email Address Primary Insurance Company
Subscriber’sName ______D.O.B. ______
Policy #Group # Student ______Relationship to Subscriber ______
Listany medical illnesses, injuries,or conditions that thestudent/applicant is currently experiencing:
Listall medications that the student/applicantis currently taking:
Emergency Contact Information:
All medical informationlisted above shall remainprivate unlessa studentis in medical danger.
Ivy Prep
Medical Release/Permission Slip
(continued)
I,permitany member of the Chi TauOmega chapter of Alpha Kappa AlphaSorority,Inc. ®/ Community C.A.R.E.S Foundation Inc.® oritsdesigneeassociatedwith this programto provide any medical assistancedeemed necessary to myabove listed childor ward.By signing thisMedical Release/ Permission Slip,I release theChi Tau Omega Chapter ofAlpha Kappa AlphaSorority, Incorporated/ Community C.A.R.E.S Foundation Inc.®,its membersand other volunteersassociatedwith this programfromany liability orinjury, loss, ordamage connectedinany way whatsoever with participation in this program.
Signing below affirms that both the student applicant and the parent/guardian understand and agree to the terms and conditions for medical treatment outlined in theMedicalRelease/PermissionSlip. Signing this form also affirms thatall medicalinformationlisted inthe MedicalRelease/Permission Slip is accurate to the best ofyourabilities.
Student’s Printed NameParent’s/Guardian’s Printed Name
Student’s Signature/DateParent’s/Guardian’s Signature/Date
Ivy Prep Counselor/Teacher/Principal Recommendation
Student’sName (Print):
(Last)(First)(MI) The above named applicant hasappliedto participate in the Community C.A.R.E.S. Foundation Inc.®
IvyPrepProgramandasks thatyouserve as acharacterand/oracademic reference.Pleaseanswer the followingquestionsinreference to the applicant’squalifications.
1.Howlong have you known thisapplicant?
2.Pleasegiveus yourimpressions of theapplicant interms of the attributeslisted below.
3.Please feelfree to makeany additional comments about theapplicant which youbelieve would be helpful to the Selection Committee inconsidering him/her asa member for Ivy Prep.
Recommender’s NameTitle
Recommender’s SignatureDate
Ivy Prep
Personal Recommendation
Student’sName (Print):
(Last)(First)(MI) The above named applicant hasappliedto participate in the Community C.A.R.E.S. Foundation Inc.®IvyPrepProgramandasks thatyouserve as acharacterand/oracademic reference.Pleaseanswer the followingquestionsinreference to the applicant’squalifications.
1.Howlong have you known thisapplicant?
2.Pleasegiveus yourappraisal of theapplicant interms of the attributeslisted below.
3.Please feelfree to makeany additional comments about theapplicant which youbelieve would be helpful to the Selection Committee inconsidering him/her asa member for Ivy Prep.
Recommender’s NameTitle
Recommender’s SignatureDate
Ivy Prep Application Check List
Pleasemake sure you havethe below listed formscompleted withallappropriatesignatures before turning this application into the Community C.A.R.E.S Foundation Inc.® Any unsigned, late, orincomplete forms will not beconsidered, rendering the application null and void. Allcompleted applications shouldhave the following inasealedenvelope:
$10Application Fee(non-refundable)
ApplicationForm (Signed)
Personal Information(Signed)
Program Models, Rules/Regulations, and Agreement (Signed)
Parental Consent/Permission Slip(Signed)
MediaRelease/PermissionSlip(Signed)
Medical Release/Permission Slip(Signed)
Counselor/Teacher/PrincipalRecommendationForm(Signed)2requiredperapplicant
PersonalRecommendation Form(Signed)
Attached Personal Statement (250 words typed in12-inchfont and double-spaced)
ApplicationChecklist (Signed)
I,have double checked myapplication.I am sure thatIhave completed everyformwith the appropriateinformationand requiredsignatures.My PersonalStatementisattached to myapplicationand the required$10Application Fee (non-refundable) is enclosed with this IvyPrep Application.
I,understand the requirementsfora completed applicationand the consequences for failing to submitacompleted application based on the informationlisted above.
Signing below affirms that both the student/applicant and the parent understand the requirements fora completed application.Signingalso confirms thattheapplicant has checked tomakesureall required items are enclosed in the Application Packet (envelope).
Student’s Printed NameParent’s/Guardian’s Printed Name
Student’s Signature/DateParent’s/Guardian’s Signature/Date