Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program. 1 2017-18 Enrollment Application Student Name: ____________________________________ Current Grade: ______________ Middle School: ____________________________________ Date Submitted: _____________ High School*: ______________________________________ Submit Application to: Chardonnay Hightower-Collins, Operations Coordinator Email: [email protected]Phone: (510) 835-1770 ext. 434 College Track Oakland 117 Broadway Oakland, CA 94607 Checklist of items that must be returned to College Track: ! Completed Student and Parent Information ! Signed Release of Confidential Information ! Signed Evaluation Consent and Assent Forms ! Two letters of recommendation, from a teacher and/or a counselor (A third optional letter may be submitted from any non-related adult) To ensure that your completed application is received, we recommend keeping a copy of all submitted files. Students who submit completed applications on or before the deadline will be invited to College Track for an interview and an essay support workshop. For all students graduating in 2019 and later, we will only accept students attending our partner high schools (see page 3). APPLICATION DEADLINE: March 12, 2018
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Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
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2017-18 Enrollment Application Student Name: ____________________________________ Current Grade: ______________ Middle School: ____________________________________ Date Submitted: _____________ High School*: ______________________________________ Submit Application to: Chardonnay Hightower-Collins, Operations Coordinator Email: [email protected]
Phone: (510) 835-1770 ext. 434
College Track Oakland 117 Broadway
Oakland, CA 94607
Checklist of items that must be returned to College Track: ! Completed Student and Parent Information
! Signed Release of Confidential Information
! Signed Evaluation Consent and Assent Forms
! Two letters of recommendation, from a teacher and/or a counselor (A third optional letter may be submitted from any non-related adult)
To ensure that your completed application is received, we recommend keeping a copy of all submitted files. Students who submit completed applications on or before the deadline will be invited to College Track for an interview and an essay support workshop. For all students graduating in 2019 and later, we will only accept students attending our partner high schools (see page 3).
APPLICATION DEADLINE: March 12, 2018
Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
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College Track is looking for committed students who are motivated to obtain a college education and are ready for the rigorous structure and support that we provide. What is College Track? College Track is an after-school and summer college completion program that helps first generation and low-income students who have the motivation but lack the resources and support to obtain a college education. We help our students succeed in getting through high school, into college and to college graduation. We provide the tools and opportunities our students need to realize their dreams: academic support, extracurricular activities, community service, internships, and assistance in all aspects of the college application process. How does College Track help students get into college? College Track’s approach is intensive, comprehensive, and personalized so that we can best meet the needs of all of our students. College Track students are expected to participate in each of our three programs:
• Academic Affairs ensures that our students are both eligible and competitive for college admissions through tutoring, ACT prep, and academic counseling. It ensures that students are ready for the rigors of college classes by helping students develop the habits and skills they will need to succeed on campus.
• Student Life provides opportunities for students to explore their passions and dreams through experiential learning and community service opportunities during the school year and summer, mentorship, and workshops.
• College Completion provides support and guidance to students all the way through college graduation, exposing students to colleges and universities, helping students find summer programs on college campuses, visiting colleges, completing the application and enrollment process, and supporting students once they arrive on campus. It also assists students with financial preparation for college.
When does it start and what is a typical day like? At the beginning of each semester, students attend an orientation and create their weekly College Track schedule, signing up for weekly workshops and tutoring sessions. Students will schedule to come in about 3-5 hours per week, on weekdays between 3:30PM and 6:30PM. During that time, they participate in one-on-one or small group tutoring depending on need and attend workshops or study groups aimed at enhancing academic performance. In addition, students work with staff and peers to pursue things they’re passionate about, ranging everywhere between photography and service at a dog shelter. Students participate in college completion classes and projects where they learn about colleges, scholarships, and how to complete their applications.
Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
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Who may apply to College Track? We serve students who are underrepresented in college – primarily first-generation and low-income students. We can support students best when we have allies at our students’ schools who are committed to working with us to ensure our students’ succeed. Applicants must attend one of our target schools to receive admission to College Track: Skyline High School Oakland High School Oakland Technical High School Coliseum College Preparatory Academy Life Academy Oakland Unity High School To inquire about becoming one of College Track’s target schools, please contact College Track at (510) 835-1770.
Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
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Section 1: Student Information All information provided in this section is to be completed by the student applying to College Track. We will use this information to contact you about an interview so please ensure all information is clearly written and accurate. A. Personal Information
Legal First Name M.I. Legal Last Name Gender ! Male ! Female
Student Email Address Home Phone
( ) Birthdate (mm/dd/yyyy)
Home Street Address Student Cell Phone
( ) Country of Birth
City State
ZIP Code ! U.S. Citizen ! Permanent Resident ! Neither
Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
Are there any special accommodations you will need? If yes, please specify: Are you an orphan/ward of the court?
! Yes ! No
Are you an English Language Learner? ! Yes ! No
What is your Middle School GPA?
What is your 7th grade Overall English Language Arts Score on California’s Smarter Balanced Assessment, also known as CAASPP? Overall Score: __________________ (Score ranges from 2288 to 2769)
What is your 7th grade Overall Mathematics Score on California’s Smarter Balanced Assessment, also known as CAASPP? Overall Score: __________________
(Score ranges from 2265 to 2802)
Are you related to a current College Track student or College Track alumni? Y/N
If Yes, what is their name and their relation to you (e.g., brother, sister, cousin, etc.)? Name: _______________________________ Relationship: __________________________
Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
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B. Academic Information School Name* Current Grade School District
Did you participate in the Aim High program?
! Yes ! No
What is your educational goal? MARK ONE ONLY
! High school diploma or GED
! Technical or trade school
! 2-year college
! 4-year college
! Master’s degree, Ph.D., or other advanced degreeWhat are other extra-curricular activities do you participate in?
! Athletics? What sports? ___________________________________
! JROTC
! Upward Bound
! Trio
! Other: __________________________________
Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
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Section 2: Parent/Guardian Information All information provided in this section is to be completed by the parent or guardian of the student applying to College Track. We will use this information to contact you about your child’s involvement in College Track. Please ensure all information is clearly written and accurate.
A. Parent/Guardian Information
Who does the student live with? ! Both parents/guardians ! Parent/Guardian #1 only ! Parent/Guardian #2 only
Which parent/guardian is the primary contact? ! Both parents ! Parent/Guardian #1 only ! Parent/Guardian #2 only
[OPTIONAL, response can be in any language] Please share 1-2 sentence(s) explaining why you want your child to be a part of College Track:
Counting all salaries and earnings of people in your household, what is the total annual yearly income? (This information will be kept confidential.)
___________________________ Do not leave blank.
Number of people in student’s household: ___________
Do not leave blank.
I. Parent/Guardian #1 Information:
First Name M.I. Last Name Languages spoken: ! English - fluent ! English – basic ! Spanish ! Cantonese ! Other: ______________________
Email Address Relation to student: (e.g. mother, father, grandmother)
_________________________
Education Level ! Did not start or finish high school ! High school degree ! Vocational school degree ! Some college (currently enrolled) ! Some college (not currently enrolled) ! 2-year college degree ! 4-year college degree ! Graduate degree In what country did you earn your highest degree? _______________________________
Daytime phone
( )
Cell Phone
( )
Employment: ! Full time occupation: ___________________ ! Not working ! Part time occupation: ___________________ ! Disabled ! Other (please specify: __________________)
Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
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II. Parent/Guardian #2 Information
First Name
M.I. Last Name Languages spoken: ! English - fluent ! English – basic ! Spanish ! Cantonese ! Other: __________________________
Email Address Relation to student:
Education Level ! Did not start or finish high school ! High school degree ! Vocational school degree ! Some college (currently enrolled) ! Some college (not currently enrolled) ! 2-year college degree ! 4-year college degree ! Graduate degree In what country did you earn your highest degree? _______________________________
Daytime phone
( )
Cell Phone
( )
Employment: ! Full time occupation: ___________________ ! Not working ! Part time occupation: ___________________ ! Disabled ! Other (please specify: __________________)
Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
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B. Healthcare Provider Information
Healthcare Provider Does student have a primary care physician? ! Yes ! No
Name of physician
Policy Number Phone
( ) Street Address City
State
ZIP Code
C. Emergency Information Give the name, address, and phone number of an adult who does not live with you but can be contacted in the event of an emergency. You must list at least one telephone number.
Name Relationship to student
Home Phone
( ) Cell Phone
( ) Street Address City
State
ZIP Code
Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
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Release of Confidential Information to Authorized Persons/Organizations Student Name* (Print): ___________________________________________________________ Student’s Date of Birth: ______________________________________________ Month Day Year
Middle School: ______________________________ High School: ___________________________________ Expected High School Graduation Year: ______________________ Student’s School ID Number: _________________ Student’s State ID Number (CSIS #): _________________ Parent/Guardian Signature: _________________________________________________________________ *As shown on birth certificate (legal name). This can be found on student’s high school transcript.
I hereby give permission for my child to participate in the activities of College Track. I have read the information about College Track and I am in support of my child’s participation. I will allow College Track to transport my child to and from College Track sponsored activities and their office, located at College Track (117 Broadway Oakland, CA 94607) II. I hereby grant College Track and its legal representatives and assigns, the irrevocable and unrestricted right to use and publish my child’s first name and initial to last name and all image and personality rights, including film, photograph, tape or video reproduction (together, “Materials”) in which my child may be included, for editorial, trade, advertising, website marketing and any other purpose and in any manner and medium (now existing or hereafter developed); to alter the same without restriction; and to copyright the same. I hereby release College Track and its legal representatives and assigns from all claims and liability relating to said Materials. INITIAL HERE__________ Even if my student is not accepted into the College Track program, III. I hereby authorize College Track to access data from the District as well as have access to and make copies of my child’s high school records (grades, test scores, attendance, enrollment) through the completion of high school and into post-secondary education. IV. I further authorize College Track to request, share and use all information held by College Track and its partners relating to me, with all higher education institutions and program partners for the purposes of enhancing my chances of graduating from college. This includes, but is not limited to, personal information (such as my name, mailing address, email address and date of birth), high school and college academic information (such as my high school courses, grades, test scores, college transcripts), financial information (such as any scholarships, financial aid and grants awarded to me), my recorded image and voice, and my applications, admissions, enrollment, attendance and academic status at higher education institutions (together, “My Information”). V. College Track monitors the progress of applicants and participants to better evaluate the effectiveness of its high school and college program in light of its charitable mission. As part of the monitoring process, College Track may share “My Information” with researchers and funders. I understand that College Track will take appropriate steps designed to secure and protect this information, to keep it confidential, and to prevent others from connecting it to me. To the extent possible, except as set forth in this form, any information that could identify me will be removed or changed before such information is shared with other researchers, organizations, or institutions and before any research results are made public in an aggregated form. Any waiver, modification or amendment of this form will be effective only if acknowledged and agreed to by College Track. Further, I understand that College Track will maintain a record of this form, that I am entitled to request and receive a copy, and that I may wish to make a copy of this form for my own records. This form will be governed by and construed in accordance with the laws of the State of California. College Track is a California Public Benefit organization (501(c)3).
Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
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Student Assent to Participate in the
Evaluation of the College Track Program
College Track would like to evaluate how well the College Track Program is working and has contracted Mathematica Policy Research, Inc. to do the evaluation. As a part of the evaluation, we would like your permission to collect some information, like your College Track enrollment application, scores from tests administered by the College Board (such as the SAT or AP exams), scores from tests administered by ACT, Inc. (such as ACT or PLAN), and postsecondary records from the National Student Clearinghouse.
All the information you give will be kept confidential and used only for the evaluation. Your name will never be used in reporting the results of the evaluation.
We will also ask your parent/guardian(s) about your participation in this evaluation, but you can still decide at any time not to participate if you don’t want to. If you choose not to participate in this evaluation, you will not be eligible to participate in the College Track Program. Agreeing to participate in the evaluation does not guarantee admission to the College Track Program.
If you have any questions about the evaluation, please feel free to call Sarah Crissey at 510-285-4640. If you have any questions about your rights as a research volunteer, please call the Health Media Lab Institutional Review Board at 202-753-5040.
I have read the above information and I want to participate.
I hereby authorize ACT, Inc. (“ACT”) to release any and all test score reports to
Mathematica for the purpose of evaluating the College Track Program. This authorization
is effective immediately and will remain in effect until revoked by me in writing. I hereby
release and hold harmless ACT and its agents from any and all liability that may result
from, arise out of, or be related in any way to any disclosure of records or information
pursuant to this AUTHORIZATION TO RELEASE PERSONAL INFORMATION.
Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
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Evaluation of the College Track Program
Permission to Collect Data for the Sole Use of the Evaluation Study Purpose College Track would like to evaluate how well the College Track Program is working and has contracted with Mathematica Policy Research, Inc. (“Mathematica”) as an independent evaluator. Mathematica will collect student data, including information from the College Track enrollment application, SAT and ACT scores, and postsecondary records from the National Student Clearinghouse. The information we collect will help us understand the outcomes of College Track applicants. Please indicate below if you give Mathematica permission to collect the following information on your student for this evaluation. Your participation in the evaluation is voluntary and you or your student may change your mind at any time. If you choose not to participate in this evaluation, your student will not be eligible to participate in the College Track Program. Agreeing to participate in the evaluation does not guarantee admission to the College Track Program.
Confidentiality Mathematica has strict procedures to store data securely and ensure the confidentiality of your child’s information. The information you provide will be used only for the evaluation. Your name and your student’s name will never be used in reporting the results of the study. Please sign here to indicate your understanding of the study components as stated and your willingness to cooperate with this data collection effort. PARENT/GUARDIAN SIGNATURE: __________________________________________________________________ PARENT/GUARDIAN NAME:__________________________________________________ DATE: _______________
If you have any questions regarding this study, please contact Sarah Crissey at 510-285-4640 or [email protected]. If you have any questions about you and your child’s rights as research volunteers, please call the Health Media Lab Institutional Review Board at 202-753-5040.
Data Collection College Track Enrollment Application We would like to request your student’s enrollment application for the College Track Program. This will allow us to identify applicants to the program and will provide some background information on applicants.
Initial here: ________ YES, I will ALLOW the release of the enrollment application for the College Track Program for the purpose of this evaluation.
College Board Test Scores In the future, if your student takes tests administered by the College Board (such as the SAT or AP exams), we would like to request your student’s scores from the College Board. In order to obtain this information, we will need to share some personal information with them.
Initial here: ________ YES, I will ALLOW Mathematica to share my student’s personal information with the College Board in order to gain access to his/her test scores.
Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
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ACT Test Scores In the future, if your student takes tests administered by ACT, Inc. (such as the ACT or PLAN), we would like to request your student’s scores from ACT, Inc. In order to obtain this information, we will need to share some personal information with them.
Initial here: ________
Initial here: ________
YES, I will ALLOW Mathematica to share my student’s personal information with ACT, Inc. (“ACT”) in order to gain access to his/her test scores.
I hereby authorize ACT to release any and all test score reports to Mathematica for the purpose of evaluating the College Track Program. This authorization is effective immediately and will remain in effect until revoked by me in writing.
I hereby release and hold harmless ACT and its agents from any and all liability that may result from, arise out of, or be related in any way to any disclosure of records or information pursuant to this AUTHORIZATION TO RELEASE PERSONAL INFORMATION.
Postsecondary Records We would like to request your student’s postsecondary records from the National Student Clearinghouse, which is a non-profit organization that facilitates the exchange and understanding of student enrollment and related information. Data we will collect may include information on enrollment in two- and four-year colleges, degree and major type, and completion. In order to obtain this information, we will need to share some personal information with them.
Initial here: ________
YES, I will ALLOW Mathematica to share my student’s personal information with the National Student Clearinghouse in order to gain access to his/her postsecondary records.
Information for Releasing Student Data Please provide us with the following information so that your records can be released to Mathematica Policy Research, Inc. for the purpose of the Evaluation of the College Track Program.
PLEASE PRINT Q1. What is your student’s name? _________________________ ___________ __________________________________ FIRST NAME MIDDLE INITIAL LAST NAME Q2. What is your student’s Social Security number? (optional) | | | | - | | | - | | | | | Q3. What is your student’s gender? ! Female
! Male Q4. What is your student’s date of birth? | | | / | | | / | | | | | Month Day Year Q5. What is the name and address of the high school your student plans to attend?
HIGH SCHOOL NAME: CITY: STATE:
Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
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Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
Recommendation can also be submitted online at https://tinyurl.com/CT2018Rec (CT Oakland Only) The student listed below is applying to join College Track. College Track is a national college completion program that supports students from the summer after 8th grade all the way through college graduation. Thank you in advance for your time. 1. Student’s Name: ___________________________________________________________________________ Your Name: ____________________________________________ Role: _____________________________ School / Organization: ________________________________________________________________________ Phone: ( ) _________________________ Email: ____________________________________________ Your Signature: _____________________________________ Date: ______________________________
Please return your recommendation in a signed, sealed envelope to the applicant before March 12.
1. Student sets goals and reaches them with diligence. ! Always ! Usually ! Sometimes ! Rarely
2. Student demonstrates strong academic work habits.
! Always ! Usually ! Sometimes ! Rarely
3. Student overcomes setbacks and obstacles. ! Always ! Usually ! Sometimes ! Rarely
4. Student reacts productively to disappointment or failure.
! Always ! Usually ! Sometimes ! Rarely
5. How does this student demonstrate good decision-making, especially when faced with an opportunity to make a bad decision? ______________________________________________________________________________________
Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
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6. Please share an example of a time that this student took a positive risk - something that may have been difficult to do but helped this student grow. ______________________________________________________________________________________
Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
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9. For each of the following statements about the student, please indicate how accurate or
inaccurate they are.
This student:
VERY INACCURATE
MODERATELY INACCURATE
NEITHER ACCURATE
NOR INACCURATE
MODERATELY ACCURATE
VERY ACCURATE
a. Is always prepared 1 □ 2 □ 3 □ 4 □ 5 □
b. Leaves his/her belongings around 1 □ 2 □ 3 □ 4 □ 5 □
c. Pays attention to details 1 □ 2 □ 3 □ 4 □ 5 □
d. Makes a mess of things 1 □ 2 □ 3 □ 4 □ 5 □
e. Gets tasks done right away 1 □ 2 □ 3 □ 4 □ 5 □
f. Often forgets to put things back in their proper place 1 □ 2 □ 3 □ 4 □ 5 □
g. Likes order 1 □ 2 □ 3 □ 4 □ 5 □
h. Shirks his/her duties 1 □ 2 □ 3 □ 4 □ 5 □
i. Follows a schedule 1 □ 2 □ 3 □ 4 □ 5 □
j. Is exacting in his/her work 1 □ 2 □ 3 □ 4 □ 5 □
10. Is there anything else that you would like CT to know about this student?
Please return your recommendation in a signed, sealed envelope to the applicant before March 12.
Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
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Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
The student listed below is applying to join College Track. College Track is a national college completion program that supports students from the summer after 8th grade all the way through college graduation. Thank you in advance for your time. 1. Student’s Name: ___________________________________________________________________________ Your Name: ____________________________________________ Role: _____________________________ School / Organization: ________________________________________________________________________ Phone: ( ) _________________________ Email: ____________________________________________ Your Signature: _____________________________________ Date: ______________________________
Please return your recommendation in a signed, sealed envelope to the applicant before March 12.
1. Student sets goals and reaches them with diligence. ! Always ! Usually ! Sometimes ! Rarely
2. Student demonstrates strong academic work habits.
! Always ! Usually ! Sometimes ! Rarely
3. Student overcomes setbacks and obstacles. ! Always ! Usually ! Sometimes ! Rarely
4. Student reacts productively to disappointment or failure.
! Always ! Usually ! Sometimes ! Rarely
5. How does this student demonstrate good decision-making, especially when faced with an opportunity to make a bad decision? ______________________________________________________________________________________
Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
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6. Please share an example of a time that this student took a positive risk - something that may have
been difficult to do but helped this student grow. ______________________________________________________________________________________
Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
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9. For each of the following statements about the student, please indicate how accurate or
inaccurate they are.
This student:
VERY INACCURATE
MODERATELY INACCURATE
NEITHER ACCURATE
NOR INACCURATE
MODERATELY ACCURATE
VERY ACCURATE
a. Is always prepared 1 □ 2 □ 3 □ 4 □ 5 □
b. Leaves his/her belongings around 1 □ 2 □ 3 □ 4 □ 5 □
c. Pays attention to details 1 □ 2 □ 3 □ 4 □ 5 □
d. Makes a mess of things 1 □ 2 □ 3 □ 4 □ 5 □
e. Gets tasks done right away 1 □ 2 □ 3 □ 4 □ 5 □
f. Often forgets to put things back in their proper place 1 □ 2 □ 3 □ 4 □ 5 □
g. Likes order 1 □ 2 □ 3 □ 4 □ 5 □
h. Shirks his/her duties 1 □ 2 □ 3 □ 4 □ 5 □
i. Follows a schedule 1 □ 2 □ 3 □ 4 □ 5 □
j. Is exacting in his/her work 1 □ 2 □ 3 □ 4 □ 5 □
10. Is there anything else that you would like CT to know about this student?
Please return your recommendation in a signed, sealed envelope to the applicant before March 12.
Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
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Left Blank Intentionally
Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
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Optional Recommendation Form* (*This form is optional, but if it is completed, it must be from a non-related adult [e.g. coach, community leader, etc.)
The student listed below is applying to join College Track. College Track is a national college completion program that supports students from the summer after 8th grade all the way through college graduation. Thank you in advance for your time. 1. Student’s Name: ___________________________________________________________________________ Your Name: ____________________________________________ Role: _____________________________ School / Organization: ________________________________________________________________________ Phone: ( ) _________________________ Email: ____________________________________________ Your Signature: _____________________________________ Date: ______________________________
Please return your recommendation in a signed, sealed envelope to the applicant before March 12.
1. Student sets goals and reaches them with diligence. ! Always ! Usually ! Sometimes ! Rarely
2. Student demonstrates strong academic work habits.
! Always ! Usually ! Sometimes ! Rarely
3. Student overcomes setbacks and obstacles. ! Always ! Usually ! Sometimes ! Rarely
4. Student reacts productively to disappointment or failure.
! Always ! Usually ! Sometimes ! Rarely
5. How does this student demonstrate good decision-making, especially when faced with an opportunity to make a bad decision? ______________________________________________________________________________________
Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
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6. Please share an example of a time that this student took a positive risk - something that may have been difficult to do but helped this student grow. ______________________________________________________________________________________
Promise of Confidentiality: The application and any additional information provided will remain the confidential property of the College Track Program.
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9. For each of the following statements about the student, please indicate how accurate or
inaccurate they are.
This student:
VERY INACCURATE
MODERATELY INACCURATE
NEITHER ACCURATE
NOR INACCURATE
MODERATELY ACCURATE
VERY ACCURATE
a. Is always prepared 1 □ 2 □ 3 □ 4 □ 5 □
b. Leaves his/her belongings around 1 □ 2 □ 3 □ 4 □ 5 □
c. Pays attention to details 1 □ 2 □ 3 □ 4 □ 5 □
d. Makes a mess of things 1 □ 2 □ 3 □ 4 □ 5 □
e. Gets tasks done right away 1 □ 2 □ 3 □ 4 □ 5 □
f. Often forgets to put things back in their proper place 1 □ 2 □ 3 □ 4 □ 5 □
g. Likes order 1 □ 2 □ 3 □ 4 □ 5 □
h. Shirks his/her duties 1 □ 2 □ 3 □ 4 □ 5 □
i. Follows a schedule 1 □ 2 □ 3 □ 4 □ 5 □
j. Is exacting in his/her work 1 □ 2 □ 3 □ 4 □ 5 □
10. Is there anything else that you would like CT to know about this student?
