21st Century Learning Center
“Building Scholar for the Future”
Program Application
Student Information
Please print or type the requested information clearly
Program Site ______Date______
Name______
Address______
City______State______ZipCode______
Sex r Male r Female Date of Birth ______/______/______
Home Phone ______Email ______
Cell phone number ______
School ______Grade ______
Ethnicity: r American Indian/Native American rAsian/Pacific Islander
rAfrican American r Latina/o r White/ Caucasian rOther:______
Primary language spoken at home: ______
Secondary langugage spoken at home: ______
What is your current grade points average (g.p.a) :______
During your last semester, how many times were you absent from class:
rNo absences r1-5 absences r5 or more
Parent Information
Guardian’s Name ______
Relationship to Guardian______
Address (if different)______
City______State______Zip Code______
Home Phone______Work Phone ______
Cell Phone______Email ______
Martial Status ______
Guardian’s Education Level (Check the Highest):
r Kindergarten– 6th grade rHigh School Diploma rGraduate Degree
r7th-8th Grade r AA Degree r Post Graduate Degree
rSome High School r BA Degree
Family Financial Information
Number of Family Members ______Family Income ______
Do you/your child receive any of the following?
r Free/Reduced Lunch r Public Housing r Food Stamps r TANF
r Unemployment r WIC r SS/SSI r Other
Emergency Contact and Health Information
Name ______
Relationship to Student ______
Phone Number ______
If the student has any condition that may require special treatment it is imperative that a medical provider is alerted. Please indicate below any on-going medical or emotional problems that may require special attention (e.g., epilepsy, allergies, asthma, disability, anxiety, depression, etc.). Use reverse side if necessary.
______
Has the student had any major illness during the past year? ______If so, please explain: ______
Date of last tetanus injection: ______
Are contacts or glasses worn? ______
Does the student take any prescribed or over-the-counter medications? ______If so, what are they?______
Allergies to medications, food, etc.:______
“Building Scholars for the Future”
Parental Agreement Form
Parent/Guardian Name:______
First Middle Last
Child’s Name:______
First Middle Last
Please initial the following:
_____I commit to ensuring my child attends the GapBuster, Inc Building Scholars for the Future program regularly and completes all related assignments and activities.
_____I give my consent for both GapBuster, Inc to request and receive my child’s (named above) current and previous grade, disciplinary records, and/or attendance reports directly from school administration.
_____In the event that current or previous grade reports are not available or not attainable from my child’s school administration, I commit to providing GapBuster, Inc copies or reports of my child’s grades, or disciplinary records, and/or attendance.
_____I understand that without this signed and completed release form, my child’s application will be incomplete, and he/she may be denied admittance into the GapBuster, Inc Building Scholars for the Future program.
GapBuster, Inc. will ensure that all grade and attendance information remains strictly confidential. GapBuster staff will not share the any personal identifiers with any agencies or parties outside of GapBuster, Inc Building Scholars for the Future program.
______
Guardian Signature Date
Media Consent Form
I hereby grant full permission to GapBuster, Inc Building Scholars for the Future program to use my child’s photograph, videos, anecdotes, and name (if necessary) in any publication or advertising materials (printed or electronic). This consent also serves to waive all rights of privacy or compensation which I may have in connection with the use of my child’s photograph and/or name.
Child’s Name______Guardian/Parent’sName ______
Phone Number ______
Signature ______
Student Survey
Student Name: ______Grade: ______
Coordinator: ______School: ______
*PLEASE COMPLETE AT BEGINNING OF THE YEAR & END OF YEAR
Please answer each question as honestly as possible. Remember that there are no right or wrong answers, so please do not answer the questions based on what you think we want to hear. Only the program coordinator will see how you answer the questions and he or she will keep your answers confidential.
1. I like to talk about what I want to be when I grow up
Not At All Like Me A Little Like Me Somewhat Like Me
Mostly Very Like Me Very Much Like Me
2. When I want something, I plan on how to get it
Not At All Like Me A Little Like Me Somewhat Like Me
Mostly Very Like Me Very Much Like Me
3. I plan to finish high school
Not At All Like Me A Little Like Me Somewhat Like Me
Mostly Very Like Me Very Much Like Me
4. When I am a grown up, I really think I will do well in the world
Not At All Like Me A Little Like Me Somewhat Like Me
Mostly Very Like Me Very Much Like Me
5. I think about going to college
Never Sometimes Often
Very Often
6. How many adults offer help with your school work?
None One 2 to 3
4 to 5 6 or more
7. How many adults pay attention to what’s going on in your life?
None One 2 to 3
4 to 5 6 or more
8. How important is going the best you can in school?
Not At All Somewhat important Important Very Important
9. When I am faced with a problem, I ask someone I respect for advice
Not At All Likely Not Very Likely
Somewhat Likely Very Likely
PERSONAL AND PROFESSIONAL GOALS
Are you planning to attend college after graduation? cYes c No
If “yes” do you plan to: if “no” do you plan to:
c Attend a 4 year college c Work
c Attend a 2 year college c Military Service
c Other
What would be your ideal g.p.a. for this coming semester? ______
If you are planning on attending college, what would you like to study?
What profession do you anticipate having a career in?
Whose leadership skills do you admire and why?:
What type of extracurricular activities do you participate in whether at school or outside of school? (sports, clubs, band, volunteer organizations, church groups coaching, etc.)
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