Roanoke Rapids Early College High School

Roanoke Rapids Early College High School

Scholar/Family Application

Please turn in the completed application to the Chaloner Middle School counselors (Jennifer Clapton or Sabrina Hunter), Roanoke Rapids High School counselor (Jessica Elias), or RRGSD Central Services (Julie Thompson) by April 9, 2018.

Scholar Information
First Name / Middle Name / Last Name
Preferred Name / Birth Date / Gender
Address
**RRGSD Email Address (if applicable) / Phone Number
Name of School Scholar Currently Attends / Current Grade

** Please include a valid email address. If you are not a current RRGSD student, provide your personal email address. We will contact all applicants regarding your admission status via email.

Describing Yourself

Circle the characteristics that best describe you. Circle all that apply.

Creative / Team player / Good time management skills
Shy / Misunderstood / Disconnected from traditional school
Friendly / Independent thinker / Needs attention
Flexible / Strong leadership skills / Able to walk away from conflict
Loner / Readily accepts authority / Needs help with organization

Please complete the following responses. You may use the back if you need more room; you may write or type your answers on a separate sheet to attach; or you may download this document, type, and print to submit. All applications must be signed.

Activities and Interests

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/Service Activities:

About You

Think about your favorite class or subject 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:

Goals and Plans

What goals do you plan to achieve as a high school student at the Roanoke Rapids Early College High School?
What plans have you considered and/or what dreams do you have for your life after high school? :

Interest in Roanoke Rapids Early College High School

Explain why you are interested in attending Roanoke Rapids Early College High School. What special talents and/or skills can you contribute to the Early College?

Other Information

Is there other information that you would like for us to know about you?
Family Information
Name of Parent/Guardian Completing This Form / Relationship to Scholar
Residence (With whom does the scholar live?)
______Mother
______Father
______Father and Mother / ______Mother and Stepfather
______Father and Stepmother
______Grandparents / ______Guardian/Other (explain)
Mailing/Contact (for scholar) Address
Home Phone Number / Work Phone Number / Cell Phone Number
Email Address
Parent/Guardian Information
Parent/Guardian #1 Name
Address (if different from the address above)
Last Grade Completed (circle one)
1 2 3 4 5 6 7 8 9 10 11 12 / Did you attend college? ______
If yes, what college?
Years Completed (circle one)
1 2 3 4 4+
Year Graduated:
Current Employer / Position
Other Family Members Attending or Who Have Attended College:
Parent/Guardian Information
Parent/Guardian #2 Name
Address (if different from the address above)
Last Grade Completed (circle one)
1 2 3 4 5 6 7 8 9 10 11 12 / Did you attend college? ______
If yes, what college?
Years Completed (circle one)
1 2 3 4 4+
Year Graduated:
Current Employer / Position
Other Family Members Attending or Who Have Attended College:
Household Income Range (What is the yearly income of your family?)
______less than $13,000
______$36,000 - $45,000
______$65,000 - $75,000 / ______$13,000 - $23,000
______$45,000 - $55,000
______more than $75,000 / ______$23,000 - $36,000
______$55,000 - $65,000

Signature and Agreement

By signing the application, I am acknowledging that I wish to be accepted into Roanoke Rapids Early College High School. I certify the information provided above is complete and accurate. I further agree to observe all rules and regulations of Roanoke Rapids Early College High School and Roanoke Rapids Graded School District. We agree the applicant will remain at Roanoke Rapids Early College High School for the entire 2018-19 school year.

Signature of Scholar Applicant ______Date ______

Signature of Parent/Guardian ______Date ______

(if applicant is under 18 years of age)

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