San Ramon Valley Unified School District Collegeconnect

San Ramon Valley Unified School District CollegeConnect

Program Application

Applicationswillbeacceptedasspaceisavailabletoqualifiedapplicants.

PLEASECOMPLETETHISAPPLICATIONBYPRINTINGININK

Name of Student: / Male Female
Date of Birth: / Student ID #
Name of Parent/Legal Guardian:
Home Street Address: / City, State & Zip
Parent’s Primary Phone: / Other Contact Number:
Parent email: / Student email:
List any athletics and/or extracurricular activities that you are currently or planning on participating in:

HighSchoolAttendanceArea: Schoolpresentlyattending:

PLEASEREADCAREFULLY:BysubmittingthisapplicationyouunderstandthecommitmentofeffortandtimeyourchildisundertakingifacceptedintotheSan Ramon Valley Unified School District (SRVUSD)CollegeConnect Pilot Program.Thiscommitmentincludesagreeingtokeepyourchildintheprogramfor2schoolyears, including one course per summer. IfattheendofanyhighschoolyearyourchildisunwillingorunabletocontinuestudiesintheSRVUSDCollegeConnect Pilot Program,she/hemaybereassignedtothehighschoolofher/hisattendancezone.

Interviewsmaybeconductedforqualifiedcandidates. Attendanceand/orbehaviorproblemsmaybesufficientcausetoremovethestudentfromtheprogram.

(Parent/GuardianSignature)Date:

Please deliver completed applications to:

Educational Services – Building C

699 Old Orchard Drive

Danville, CA 94526 (925) 552-2916

………………………………………………………………………………………………………………………………….……

ForOfficeUseOnly:

StudentisrecommendedfortheSRVUSDCollegeConnect Pilot Program

Studentis#onawaitinglistfortheSRVUSDCollegeConnect Pilot Program

StudentisnoteligiblefortheSRVUSDCollegeConnect Pilot Program

Reasonforineligibility:

SignatureofSRVUSD district administrator Date

SignatureofDVC San Ramon administrator Date

Signature of SRVUSD site principalDate

Student Name:

Pleaseanswerthefollowingquestions.Youmayattachanadditionalpageasneeded.

1.Whatareyourgoalsforthefutureandhow wouldthis program help you attainthose goals?

2.Describeyouracademicstrengths andweaknesses(include favorite/least favoritesubjects):

3.What doyou think ittakes to besuccessfulin a college course?In yourfuturecareer?

4.Do you participate any extra-curricular activities or sports that might conflict with your college coursework?

5.Ifyou weretochooseyour career now whatwoulditbe?

6.Icommittofulfilling the following expectationsforSRVUSDCollegeConnect Pilot Program students:

Maintaina3.0cumulativeGPA.(IfyourcumulativeGPAfallsbelow3.0afteryouhavebeenacceptedintotheprogram,youwillbeplacedonacademicprobation.)
Thepursuitofpost-secondaryeducation/training.
Devotingaminimumof2hourseacheveningtohomeworkandstudy.
Arrivingatschooldailyandtoallclassesontime.
CompletingallSRVUSDCollegeConnect Pilot ProgramandSRVUSDgraduationrequirements.
ParticipatinginallStateandDistrictacademictestingrequirements.
Keepingmyparents/guardian(s)informedofmyacademicprogressintheSRVUSDCollegeConnect Pilot Program.

StudentSignature:Date:

StudentName: Pleaseanswerthefollowingquestions.Youmayattachanadditionalpageasneeded.

1.How doyouthinkyourstudentwillbenefitfrom theSRVUSDCollegeConnect Pilot Program?

2.Whatarethestrengthsandweaknesses ofyourstudent asevidencedthroughtheeducationalprocess?

Students succeedbest whentheschoolstaff,theparent(s) and the studentworktogether.Bysigningbelow,youareagreeing tothe followingexpectations forSRVUSDCollegeConnect Pilot Program?

Providefor2hourseachevening forstudents to studyand dohomework.
Support regularattendanceand callschoolon the dayof an absence.
Ensurestudentsparticipate in allState and District academic testingrequirements.
Attendandparticipateinschoolfunctions.
Be aware of allSRVUSDCollegeConnect Pilot Program activities byreadingallmaterials senthome.
Reviewandfollowup onProgressReportsandReport Cards.
Participateinall required SRVUSDCollegeConnect Pilot Program activities.
Encourage andexpect studentstopursuepost-secondaryeducationor training aftergraduation.
Contactschool if youhavea questionor ifthereisagap ininformationcominghome.

ParentSignature:Date:

Teacher/Counselor Input Form

Student’s Name:CurrentSchool:Teacher/CounselorName: Title: Howdoyouknowstudent? How long?

Theabovestudent isapplying fortheSRVUSDCollegeConnect Pilot Program.Students enrolledinthisprogramcompletetheirhighschooleducationwithaschedulethatincludesupto30 units ofcollege course work.Your responsesarevaluable inhelpingtheSRVUSDCollegeConnect Pilot Program staff identify whichstudents willbenefit fromandsucceedintheprogram.

Characteristics,typicalofstudents for whomtheprogramwasdesigned, arelistedbelow.Please evaluate thestudent’scharacteristicsby circlingoneforeach category:

Attendance / excellent / good / fair / poor / inconsistent / NA
Student Leadership / excellent / good / fair / poor / inconsistent / NA
Independent Learner / excellent / good / fair / poor / inconsistent / NA
InterpersonalSkills / excellent / good / fair / poor / inconsistent / NA
Integrity / excellent / good / fair / poor / inconsistent / NA
SocialMaturity / excellent / good / fair / poor / inconsistent / NA
Self-motivation / excellent / good / fair / poor / inconsistent / NA
Respect for Others / excellent / good / fair / poor / inconsistent / NA
Artisticabilities / excellent / good / fair / poor / inconsistent / NA
Writing Skills / excellent / good / fair / poor / inconsistent / NA
Readingskills / excellent / good / fair / poor / inconsistent / NA
Seeksacademic challenges / excellent / good / fair / poor / inconsistent / NA
Participatesinclassroomdiscussions / excellent / good / fair / poor / inconsistent / NA
Response to setbacks / challenges / excellent / good / fair / poor / inconsistent / NA
Study Skills / excellent / good / fair / poor / inconsistent / NA
Willingness to accept responsibility / excellent / good / fair / poor / inconsistent / NA
Capableofperformingathigherlevel / yes / no / NA

Pleasewriteabout any orallofthecommentsmarkedabove(use an additionalsheetofpaper ifnecessary):

TheSRVUSDCollegeConnect Pilot Program staffappreciatesyoureffortin completingthisapplication.Please complete this form and place it in a sealed envelope.Shouldyouhaveanyquestionsaboutthisformor the program,callEducational Servicesat925-552-2916.

Signature:Date:

Teacher/Counselor Input Form

Student’s Name:CurrentSchool:Teacher/CounselorName: Title: Howdoyouknowstudent? How long?

Characteristics,typicalofstudents for whomtheprogramwasdesigned, arelistedbelow.Please evaluate thestudent’scharacteristicsby circlingoneforeach category:

Pleasewriteabout any orallofthecommentsmarkedabove(use an additionalsheetofpaper ifnecessary):

Signature:Date:

Adult Reference Form

(Optional)

Student’s Name:CurrentSchool:AdultName: Title: Howdoyouknowstudent? How long?

Characteristics,typicalofstudents for whomtheprogramwasdesigned, arelistedbelow.Please evaluate thestudent’scharacteristicsby circlingoneforeach category:

Leadership / excellent / good / fair / poor / inconsistent / NA
Independent Learner / excellent / good / fair / poor / inconsistent / NA
InterpersonalSkills / excellent / good / fair / poor / inconsistent / NA
Integrity / excellent / good / fair / poor / inconsistent / NA
SocialMaturity / excellent / good / fair / poor / inconsistent / NA
Self-motivation / excellent / good / fair / poor / inconsistent / NA
Respect for Others / excellent / good / fair / poor / inconsistent / NA
Artisticabilities / excellent / good / fair / poor / inconsistent / NA
Writing Skills / excellent / good / fair / poor / inconsistent / NA
Readingskills / excellent / good / fair / poor / inconsistent / NA
Seeksacademic challenges / excellent / good / fair / poor / inconsistent / NA
Conversational Skills / excellent / good / fair / poor / inconsistent / NA
Response to setbacks / challenges / excellent / good / fair / poor / inconsistent / NA
Study Skills / excellent / good / fair / poor / inconsistent / NA
Willingness to accept responsibility / excellent / good / fair / poor / inconsistent / NA
Capableofperformingathigherlevel / yes / no / NA

Pleasewriteabout any orallofthecommentsmarkedabove(use an additionalsheetofpaper ifnecessary):

Signature:Date:

Please deliver all applicationmaterials toEducational Services Department, Building C, 699 Old Orchard Drive, Danville, CA 94526 no later than 3pm on March 10, 2017.The followingitemsconstituteacomplete applicationpackage:

 Program Application (pages 1-3)

2Teacher/CounselorInputForms (pages 4-5)

1Optional AdditionalAdult Reference(page 6)

Copyof Transcriptreflectingminimum3.0CumulativeGPA (available in the Reports tab in the Infinite Campus Parent Portal)

3rd Quarter Term Reportreflectingminimum3.0GPA(available in the Reports tab in the Infinite Campus Parent Portal)

Studentsmusthavetwoteachers/counselorscompletereferenceforms.Athird(optional)adultreferenceformwillalsobeacceptedandmayinclude:schooladministrators,youthgroupadvisors,clergy,coaches,scoutleader,employeroranyotheradultwhohasworkedwiththestudentinanadvisory, supervisoryormentor role.Referencescannot be related to the applicant.

Youwillbenotifiedbyphoneifyouhavebeenselectedforaninterview. Interviewsarearequiredpartof theapplication process.

DoesstudenthaveaccesstoaHomeComputer?Yes______No ______

Primarylanguagespokenathome

MaterialsenthomeneedstranslationYes______No ______

Currently enrolledinGATE? Yes______No ______

Please circle the highest level of parent education completed

Guardian 1:

Some HS Graduated HS Some college Graduated college Some grad school Completed grad school

Guardian 2 (if applicable):

Some HS Graduated HS Some college Graduated college Some grad school Completed grad school