MIDDLE CREEK HIGH SCHOOL APPLICATION FOR THE

DIGITAL MEDIA ACADEMY 2017-2018

Parent/Guardian must complete this page of the application. Please print clearly in black/blue ink. Student must complete the following pages.Applications from students to attend the Digital Media Career Academy will only be processed if the student is assigned to Middle Creek High School.For additional information contact Karen Ingram, Academy Coordinator at 919-773-3838 x21907 or email me at .

Name of Student______Sex_____Race______

Age______Date of Birth______

Name(s) of Parent/Legal Guardian that student resides with ______

Student’s Home Address ______

(street)

______

(City, State, Zip)

TELEPHONE NUMBERS
Mother/guardian / Residence Phone: / Work Phone: / Cell:
Father/guardian / Residence Phone: / Work Phone: / Cell:
Student / Residence Phone: / Cell:
EMAIL ADDRESS
Mother/guardian
Father/guardian
Student

Courses taken during the previous school year:______

______

List clubs, extracurricular activities, family activities, and hobbies that you are currently involved in or plan to engage in while being an academy student:

Sport(s) Club(s) Family Activities Hobbies

Please answer the following questions to the best of your ability.

What are your career goals? ______

______

What is your greatest strength? ______

What is one of your weaknesses?______

What three words (or two phrases) come to mind when you think of yourself? Explain your answer.

______

Have you ever been expelled, on probation, suspended and/or removed from school due to a disciplinary issue? YES/NO If YES, please describe. (Failure to provide this information could result in placing your application in jeopardy of not being accepted.)______

______

This is a rigorous program, are you committed to working hard?______

Participating in an internship is a requirement for membership in this academy. You and your parent will be required to sign a contract committing to fulfilling this requirement. Are you willing to sign the contract and abide by this requirement? ______

Students coming in to the academy will be required to purchase Academy polo shirts which are $20 are you willing to make this purchase if accepted into the Digital Media Academy? ___Yes ___No

Please write 2-3 brief paragraphs on why you are interested in the Digital Media Academy

______

______

______

______

______

______

______

Do you plan to participate in any other program such as band or chorus? _____Yes ______No

(Please note that if you checked yes this could pose a potential scheduling conflict with the Digital Media Academy that would cause you to make a decision between the programs.)

Please have two of your current teachers to complete the teacher’s recommendations that are attached.

MCHSDigital Media Academy Recommendation

To the applicant: Please complete the top section and give this form to one of your current classroom teachers listed in the application, to complete.

Student’s Name ______

LastFirstMiddle

Student’s Address ______

StreetCity, State, Zip Code

Student’s Current School ______

How long have you know the applicant? ______

In which grade and subject did you teach this applicant? ______

What is the applicant’s current grade in your class? I.e., 96 ______

To the Recommender: The student named above is applying for admission to the Digital Media Academy at Middle Creek High School. Please use this form to sharewith us your perceptions of how well this student will meet the academic and social responsibilities of the academy. In addition, please attach an official report of discipline issues. Please return this form to the student in a sealed envelope. Thank you for your assistance.

Please Check as applicable / Exemplary / Acceptable / Needs Improvement / N/A or Unknown
Knows how to actively engage in collaborative group work
Verbal Communication skills
Analytical/Problem-solving
Leadership skills
Overall quality of academic work
Dependability/reliability
Exercises critical thinking skills
Classroom behavior
Interpersonal skills
Cooperativeness

Comments:

Name of Reference______Title______

Department/Organization______Phone______

Address______

StreetCityStateZip

Signature______Date______

MCHSDigital Media Academy Recommendation

To the applicant: Please complete the top section and give this form to one of your current classroom teachers listed in the application, to complete.

Student’s Name ______

LastFirstMiddle

Student’s Address ______

StreetCity, State, Zip Code

Student’s Current School ______

How long have you know the applicant? ______

In which grade and subject did you teach this applicant? ______

What is the applicant’s current grade in your class? I.e., 96 ______

To the Recommender: The student named above is applying for admission to the Digital Media Academy at Middle Creek High School. Please use this form to sharewith us your perceptions of how well this student will meet the academic and social responsibilities of the academy. In addition, please attach an official report of discipline issues. Please return this form to the student in a sealed envelope. Thank you for your assistance.

Please Check as applicable / Exemplary / Acceptable / Needs Improvement / N/A or Unknown
Knows how to actively engage in collaborative group work
Verbal Communication skills
Analytical/Problem-solving
Leadership skills
Overall quality of academic work
Dependability/reliability
Exercises critical thinking skills
Classroom behavior
Interpersonal skills
Cooperativeness

Comments:

Name of Reference______Title______

Department/Organization______Phone______

Address______

StreetCityStateZip

Signature______Date______

NOTE: The Academy Program is a 4-Year Commitment and withdrawal from the program is highly discouraged.