Complete the following information:

Student name: Last school attended: ______

Age: Date of birth: Number of high school credits ______

EC: No YesCategory:

Indicate preference of school to conduct Differentiated Diploma:

HomeSchool

Pressly

Completion of Differentiated Diploma: The differentiated diploma program is a highly structured and limited opportunity for a select number of students whose circumstances prevent graduation from high school. Students must complete 21 required and elective credits in order to receive a North Carolina high school diploma. The program is coordinated through PresslySchool.

Referrals are submitted by the school principal and reviewed by a committee of school system staff. Only students who demonstrate a high degree ofMotivation, Cooperation, and are Self Directed will be accepted into the program.

The student application packet must be completed in order for the referral to be considered. The review committee will give strong consideration to each student’s Commitment Agreement in determining which students will be accepted. All applications must be signed by a parent/guardian.

Guidelines:

1. Students must be a junior in HS (16 credits) before admission to the program.

2. A SSP/plan should accompany every student admitted to the program.

3. Students will agree to comply with the rules and guidelines of PresslySchool.

4. Students admitted will attend the school setting deemed the most appropriate by the review committee to encourage completion of the diploma requirements. Possible settings include but are not limited to: Student’s home school, Pressly, and MonticelloSchool.

5.The Principal of Pressly School, Monticello School, or the student’s home school will have the authority to dismiss any students from the diploma program who are disruptive, uncooperative, or not making progress toward graduation.

6. Only students displaying a Significant Hardship that will impede their ability to graduate from high school in the traditional fashion or who are strongly considering dropping out of school will be admitted.

222 Knox Street◘ Statesville, NC 28677◘ 704.872.7606 ◘704.838.0839 (fax)

**I understand that submitting this application does not guarantee that I will be accepted to the program. I agree that, if accepted, I will comply with the guidelines outlined above as well as any and all expectations established at PresslySchool.

Student Signature Date

Parent Signature Date

School Personnel to be Notified Email

This box is for school use:

Date application received: Committee review date:

Received by: Accepted: Denied:

Please answer the following questions as completely as possible. Feel free to use the back side of this paper if additional space is needed. **

1. Explain how you got to the point where it is not likely that you will graduate from high school.

2. What are you going to change, either in your life or school habits, which will cause you to be successful?

Course Year Completed

4 English

Eng. I

Eng. II

Eng. III

Eng.IV

3 Math

Algebra I

4 Math for class of 2009-2010 and beyond

Sequence I:

Sequence II:

3 Science

Biology

Physical Science:

Earth/Environmental Science

3 Social Studies

Civics and Economics

World History

US History

4 CTE Pathway:

Course 1:

Course 2:

Course 3:

Completer:

1 Health and PE

Electives

#1:

#2:

#3

Required exams: All EOC’s

10th Writing

Reading Level: Please indicate

Courses remaining for graduation:

Referring Counselor SignatureDate