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Updated on 8/10/16

This Parent/Guardian Application is due to the Elon Academy Office by Friday, January 27th, 2017 with the Student Application. We will use the phone number you provided and contact you upon receipt of both applications. If you do not hear from our office, we encourage you to call us to ensure that we have received your application.

Please Print:

Name of Student:______

FirstMiddle Last

Name of Parent/ Legal Guardian completing this form: ______

Relationship to Student: ______

Residence (With whom does the student live?):

______Mother______Mother and Stepfather

______Father______Father and Stepmother

______Father and Mother______Grandparent(s)

______Guardian/Other (explain) ______

Mailing/Contact:

Household #1: Address: ______

City/State/Zip: ______

Home Phone: ______Cell Phone: ______Email: ______

Household #2 (Please complete if custody of applicant is shared between two different households and you would like both households contacted equally with updates about student’s application status):

Address:______

City/State/Zip: ______

Home Phone: ______Cell Phone: ______Email: ______

Parent/Guardian Information:

Parent/Guardian #1 Name: ______

Marital Status: ____Married ____Divorced ____Single ____Remarried ____Widow

Address: ______City/State/Zip ______

(Complete only 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: 1 2 3 4 4+ Year graduated: ______

Current Employer: ______Position: ______

Work Phone Number: ______Email: ______

Parent/Guardian Information:

Parent/Guardian #2 Name: ______

Marital Status: ____Married ____Divorced ____Single ____Remarried ____Widow

Address: ______City/State/Zip ______

(Complete only 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: 1 2 3 4 4+ Year graduated: ______

Current Employer: ______Position: ______

Work Phone Number: ______Email: ______

Other children in the applicant’s home:

Name ______Age ______Grade _____

How many children listed above are currently in college or plan to attend a 4-year college next year? _____

List any family member(s) who participate in the Elon Academy.

Name ______Relationship ______

Total Household Income Range (What is the yearly income of your family?):

______less than $24,300______$24,300 - $26,550______$26,500 - $42,500

______$42,500 - $53,100______$53,100 - $60,000______$60,000 or higher

Household Information:(please circle)

Do you live in? a house an apartment a trailer Other ______

Are you? buying renting Other (please explain) ______

Free/Reduced Lunch

Documented qualification for free/reduced lunch is recommended, but not required. Please attach the documentation to this application.

Does your student receive free or reduced lunch?YesNo Not Sure

Has your student qualified for free or reduced lunch in the past? Yes NoNot Sure

Does any child in your household qualify for free or reduced lunch?YesNoNot sure

Additional Information:

Is there any other information that you think is important for us to know?

Release of School Records:

I, ______, the parent/guardian of the Elon Academy nominee ______, grant the staff of the Elon Academy the right to request and receive my student’s school records throughout the time he/she is enrolled in the Elon Academy. If selected, I grant permission for the Elon Academy faculty and/or staff to visit my student during the school year.

Please print: Parent/Guardian’s name: ______

Please sign: ______Date: ______

Elon Academy Program CommitmentDescription of Elon Academy

The Elon Academy is a three-year, college-access, and college-success program. The goal of the Elon Academy is to engage students in challenging curricular, co-curricular, and cultural experiences to ensure that they get the essential resources that they need to lead productive, fulfilling lives. These experiences will position them to succeed in institutions of higher education and to become active members and leaders in their communities and beyond.Elon Academy support does not stop once students graduate from high school. Academy students and families continue to participate in a variety of programs and support services during college years.

How is this done?

Students accepted in the Elon Academy attend a one-month (four week) summer program on the Elon University campus. They live in residential halls and are chaperoned by experienced Elon University studentsand Elon Academy faculty and staff.
Elon Academy students and their families also participate in regular monthly programs during the traditional school year. Students are expected to meet three times per semester with an appointed mentor and have access to Elon Academy tutors to support their high school learning.
Elon Academy students and families participate in a variety of events, programs, and meetings after graduating from high school to ensure success in college.

Summer Program

Students keep a demanding schedule during the summer residential program. Their day begins at 7:30 a.m. and ends at 11:00 p.m. They take a variety of academic classes taught by highly qualified public school teachers and Elon University faculty that expose them to new concepts and better prepare them for their next school year. College Planning courses help students develop skills and understand the preparation necessary for becoming successful college students. In the evening, students participate in fun enrichment activities like music, dance, physical fitness, sports, etc. Students visit historical and/or cultural sites, businesses, and colleges, and on Saturdays, they work on community service projects such as the Community Garden and Habitat for Humanity.

Elon Academy Summer Program Dates

This year, the Elon Academy summer program is Sunday, June 18, 2017 – Friday, July 14, 2017. During the summer session, students arrive each Sunday evening at 5:00 p.m. and return home each Saturday afternoon at noon. Students go home for an extended July 4th Holiday. Vacation, camps, doctor’s appointments, and other activities that conflict with the Elon Academy program should not be scheduled. The Elon Academy staff highly discourages families from taking a student off campus during the summer residential program unless there is an emergency. Families are welcome to visit their students on campus during meal times.

Expectation for Participation

If selected, your student is expected to:

Participate in the high school phase of the program beginning Spring 2017 through high school graduation;
Attend the one-month residential (live at Elon) summer program at Elon University in the summers of 2017, 2018, and 2019;
Attend Saturday events during the academic school years 2017/18, 2018/19, 2019/20;
Meet with a College Access Team (CAT) Mentor three times each semester of high school
Participate in events and support services through college graduation;
Maintain A’s, B’s, and/or C’s as well as a 3.0 grade point average and clean disciplinary record; and
Be a positive participant in the program.

I understand that to be selected my student is required to attend an interview at his/her high school. I understand that if my student is accepted, this is a three-year plus commitment. My signature indicates that I will make the Elon Academy my number one priority for my student. I understand that full participation in the program is essential to my student’s success and agree not to plan vacations and other activities that conflict with the Elon Academy program. I also understand that a medical exam is required before residence.

Signed ______Date ______

(Parent/Guardian)

Equal Opportunity and Statement of Non-Discrimination

Elon University does not discriminate on the basis of age, race, color, creed, sex, national or ethnic origin, disability, sexual orientation, gender identity or veteran status in the recruitment and admission of students, the recruitment and employment of faculty and staff, or the operation of any of its programs. Students with documented disabilities may request in writing reasonable special services and accommodations. Questions should be directed to Ms. Katie LaPlante, Elon Academy Assistant Director of Counseling and Family Programs (336-278-6109) who will work with Ms. Susan E. Wise, Elon University Coordinator of Disability Services. The university’s Section 504 of the American With Disabilities Act Coordinator for students and the Title IX coordinator is Dr. Jana Lynn Patterson, R.N. Ellington Center for Health and Wellness, 336-278-7200, can also be consulted. The university’s deputy Title IX coordinators are Ms. Faith Shearer, Alumni Field House, 239-H, 336-278-6790, and Ms. Melissa Duncan, Director of Career and Student Development, Elon Law Room 107-M, 2005 Campus Box, Elon NC 27122, (336) 278-9256; . The university’s Section 504 coordinator for applicants and current employees is the Executive Director of Human Resources at 314 W. Haggard Ave., 336-278-5560.

As a collegiate community, Elon University will not support or condone behaviors that violate the integrity of any individual or group. While the university respects the right of its community to exercise free speech, behaviors will not be tolerated that may be considered discrimination, harassment, destruction of property or acts of violence.

Communication of a threat or harm should be directed to police immediately by calling 911. Options for seeking confidential assistance or reporting incidents of harassment or discrimination may be reported via the bias incident protocols at: