Achieve at Noble and Greenough School Solicitud de Matriculación para estudiantes en el 6to grado

Fecha Limite Prioridad: 13 de febrero 2019 Fecha Limite Final: 1 de marzo 2019

Nombre del estudiante: ______________________________________________________________________________ Género:

Nombre Segundo Nombre Apellido

Fecha de Nacimiento: ___________ / ___________ / ___________ Edad: ___________ Mes Día Año Dirección del hogar: ______________________________________________________________________________________________________ Calle y número Número de apartamento _________________________________________________________________________________________________________________________ Ciudad Estado Código Postal

Teléfono celular: (_______) _________ - ___________ Correo Electrónico: _________________________________________________________ Nacionalidad: _______________________________ Lugar de nacimiento: _________________ ________________ __________________ Ciudad Estado País Si el estudiante nació en otro país, indique cuantos años ha vivido en los Estados Unidos: _______________

¿Habla el estudiante con fluidez un idioma diferente al inglés? ❏ No ❏ Sí _____________________________________ (indicar idiomas)

Idioma principal que se habla en la casa: _____________________________________________________________________________________

¿Cómo se enteraron del programa Achieve? ❏ Amigo/Familiar ❏ Centro de Comunidad ❏ Pagina web de Achieve

❏ Maestro(a)/Consejero(a) ❏ Presentación en la escuela ❏ Otro (indicar): ________________

Escuela actual: ___________________________________________________________ Grados asistidos en esta escuela: ___________________

Grado actual: ______ ¿Cual escuela asistirá el estudiante en el 7mo grado? ________________________________________________________

Raza/Etnicidad del Estudiante (opcional): ____________________________________________________________________________________

Guardián: Guardián:

Indicar Relación: ❏ Padre ❏ Madre ❏ Padrastro ❏ Madrastra Indicar Relación: ❏ Padre ❏ Madre ❏ Padrastro ❏ Madrastra

❏ Guardián ❏ Otra: _______________________ ❏ Guardián ❏ Otra: ________________________

Nombre: __________________________________________________ Nombre: ___________________________________________________

Nombre Apellido Nombre Apellido

Dirección: _________________________________________________ Dirección: __________________________________________________ Calle y numero Apartamento Calle y numero Apartamento

PARTE 1: Información del Estudiante

Masculino Femenino

PARTE 2: Información de la Familia

_________________________________________________________ ____________________________________________________________

Ciudad Estado Código Postal Ciudad Estado Código Postal (_____) _______ - _________ (_____) _______ - _________ (_____) _______ - _________ (_____) _______ - _________ Teléfono de la casa Teléfono alterno Teléfono de la casa Teléfono alterno

Correo electrónico: _________________________________________ Correo electrónico: ___________________________________________

__________________________ _____________________________ _____________________________ ____________________________ Ocupación Empleador Ocupación Empleador

___________________________ _____________________________ ___________________________ ______________________________ País de nacimiento Etnicidad/Nacionalidad País de nacimiento Etnicidad/Nacionalidad

Idioma principal: __________________________________________ Idioma principal: _________________________________________

Achieve obtiene la siguiente información para reportar a los financiadores – esto permite que el programa sea ofrecido gratuitamente. Aplicaciones incompletas no podrán ser consideradas. Favor indicar una respuesta para cada pregunta.

1. ¿Cuál es el máximo nivel académico alcanzado por un padre o guardián?

❏ Escuela intermedia o antes ❏ Parte de la escuela secundaria ❏ Graduado de la escuela secundaria

❏ Parte de la universidad ❏ Graduado de la universidad

2. ¿Tiene el estudiante un hermano(a) ACTUALMENTE ASISTIENDO una universidad? ❏ No ❏ Sí

3. ¿Tiene el estudiante un hermano(a) que se ha GRADUADO de una universidad? ❏ No ❏ Sí

4. ¿Se habla algún idioma además del inglés en la casa? ❏ No ❏ Sí Indicar idiomas: __________________________________

5. ¿Con quien vive el estudiante? (marcar todo lo que corresponda):

❏ Padre ❏ Madre ❏ Padrastro ❏ Madrastra ❏ Guardián ❏ Otro (Relación: _________________________________)

6. Estado civil de los padres: (marcar todo lo que corresponda):

❏ Casados ❏ Separados ❏ Divorciados ❏ Nunca se casaron ❏ Madre fallecida ❏ Padre fallecido

7. Número de hermanos(as): _________ Edades: ________________________________

8. ¿Tiene el estudiante algún familiar o amigo(a) actualmente matriculado en Achieve o que esté aplicando para el programa este año? Favor indicar el nombre y relación al estudiante:

Celular Trabajo

Celular Trabajo

TO THE STUDENT: Please write a response in the space provided for each of the following short answers/essays. You may type or neatly hand-write your responses in BLUE or BLACK ink. Return To: Achieve 10 Campus Drive Dedham, MA 02026 Student’s Name: ______________________________________________ School: ________________________________________________

1. What is your favorite subject in school? Why? What is the subject that most challenges you? Why? _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________

2. Describe a situation in which you displayed your leadership abilities. _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________

3. Describe a situation during which you wish you had behaved differently or made different choices. Why did you choose to do what you did? If you could relive the experience, what would you do differently? _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________

PART 3: Student Statement

4. What do you hope to gain from attending the Achieve program? Why do you think we should choose you to be in the program? _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________

5. Please CIRCLE FIVE words that you would use to describe yourself.

Smart Cheerful Confident Cooperative Distracted Immature

Creative Curious Focused Genuine Irritable Quiet

Independent Funny Mature Patient Self-centered Shy

Lazy Dependable Athletic Lonely Happy Energetic

Impatient Loud Negative Confused Hard-working Sad

Achieve holds its scholars to high standards, both behaviorally and academically. We expect our scholars to be in attendance at both the summer and Saturday sessions with a positive attitude and a willingness to learn. Please initial each item and sign below to acknowledge that you understand the commitment. STUDENT (please initial below):

____ I am excited and committed to attend Achieve everyday for five and a half weeks this summer.

____ I will complete all class assignments and homework as required.

____ I will maintain a positive attitude and know that disruptive and inappropriate behavior is not tolerated.

I ______________________________, certify that the “Student Statement” section of the Achieve application for admission

Student’s Name

has been written by me and reflects my authentic and original ideas and experiences.

_____________________________________ Student’s Signature

Student Certification

PADRE /GUARDIÁN: Favor responder a las siguientes preguntas con bolígrafo AZUL o NEGRO. También puede escribir usando la computadora.

Enviar a: Achieve 10 Campus Drive Dedham, MA 02026 Nombre del estudiante: _________________________________________ Escuela: _________________________________________________

1. ¿Cuáles TRES palabras escogiera usted para describir su hijo(a)? ________________________________ _____________________________________ __________________________________

2. ¿Qué considera usted que son las fortalezas y debilidades académicas de su hijo(a)? _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________

3. ¿Cuál es la actitud de su hijo(a) en cuanto a su educación escolar? Favor de resumir los hábitos de estudio de su hijo(a). _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________

4. ¿Qué espera usted que haga Achieve por su hijo(a) si es aceptado al programa?

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________

PARTE 4: Declaración de Padre/Guardián

5. ¿Qué Si su hijo(a) es aceptado(a) al programa y usted decide matricularlo, usted tendrá que planificar sus eventos de familia y sus vacaciones

alrededor de las siguientes fechas. Excepto en el caso de enfermedad documentada, es obligatorio que esté presente durante todos los días del programa.

• Verano del 2019: 25 de junio – 2 de agosto

• Año Escolar 2019-2020: Dos sábados al mes

• Verano 2020: Desde la última semana de junio hasta la primera semana de agosto

• Año Escolar 2020-2021: Dos sábados al mes

• Verano 2021: Desde la última semana de junio hasta la primera semana de agosto

¿Existe algún conflicto previsto con las fechas mencionadas (verano o los sábados) ❏ No ❏ Sí

Si sí, favor de explicar el conflicto:

_______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________

6. ¿Hay alguna otra información acerca de su hijo(a) que debemos de saber?

_______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

PADRE/GUARDIÁN (favor de firmar iniciales):

____ Me encargaré de que mi hijo(a) asista regularmente y que no falte los días de Achieve.

____ Entiendo que 3 ausencias injustificadas podrán resultar en despedida del programa.

____ Me comprometo a que mi hijo(a) llegue al programa a tiempo.

_____________________________________________ _____________________________________________

Nombre de Padre/Guardián Firma de Padre/Guardián

El programa de Achieve se ha comprometido a servir estudiantes de bajos-ingresos de las Escuelas Publicas de Boston. Por lo cual, cada familia debe incluir comprobante de ingresos para que su aplicación pueda ser considerada. Toda información será mantenida confidencial. Las familias indocumentadas son bienvenidas a aplicar.

Padres/Guardianes deben de enviar los siguientes documentos de impuestos para verificación de ingresos:

✓ El formulario 1040 y el W-2 del año 2016 de la familia (las declaraciones de los impuestos - los “taxes”) o

✓ Copias de cualquier tipo de ingreso incluyendo Seguro Social (SSI), Beneficios del Welfare, Beneficios SNAP, Desempleo, o Compensación de Trabajadores, etc. (si se aplica)

Para ser elegible para el programa, los ingresos familiares no deben de sobrepasar los niveles siguientes:

• Family of 2: $32,920 • Family of 3: $41,560 • Family of 4: 50,200 • Family of 5: $58,840 • Family of 6 or more: $67,480 (add $8,640 for each family member)

PARTE 5: Verificación de Ingresos

TO THE TEACHER: THE STUDENT NAMED BELOW IS APPLYING TO ACHIEVE - A RIGOROUS TUITION-FREE ACADEMIC ENRICHMENT PROGRAM. ACHIEVE SEEKS

MOTIVATED, TALENTED STUDENTS TO PARTICIPATE IN OUR MULTI-YEAR PROGRAM, WHICH IS COMPRISED OF THREE SIX-WEEK SUMMER SESSIONS AND

SATURDAY SESSIONS DURING THE ACADEMIC YEAR. ACHIEVE IS COMMITTED TO SERVING LOW-INCOME MIDDLE SCHOOL STUDENTS WHO WOULD THRIVE IN A

COMMUNITY WHERE ACADEMIC AND SOCIAL STANDARDS ARE HIGH. ABOVE ALL, ACHIEVE SEEKS STUDENTS WHO WILL COMMIT TO ATTENDING ALL SESSIONS

AND WHO WILL WORK HARD! WE APPRECIATE YOUR CANDID RESPONSES AND THANK YOU FOR YOUR HELP IN THIS PROCESS.

PLEASE NOTE: THIS REFERENCE WILL BE KEPT CONFIDENTIAL AND SHOULD BE SUBMITTED DIRECTLY TO ACHIEVE BY THE TEACHER. REFERENCES SUBMITTED BY APPLICANTS WILL NOT BE ACCEPTED.

Return To: Achieve 10 Campus Drive Dedham, MA 02026 Student’s Name ______________________________________ Student’s School _________________________________________________ Teacher’s Name ________________________________________ Subject(s) _______________________________________________________

Does the student currently have an IEP? ❏ Yes ❏ No

1. Please describe this student’s academic performance, conduct, and effort in your class. 2. Does the student have difficulty grasping new concepts and retaining information? Does he/she seek help when needed? 3. Do the student’s grades truly reflect his/her academic ability? If not, where is the disconnect between the student’s grades and ability? 4. The Achieve program is a very rigorous academic environment. How do you think this student will respond to high academic and behavioral standards? 5. How could Achieve benefit this student? If accepted, what might this student contribute to the program?

PART 6A: Teacher Reference (English or Math only)

Please circle the response that best suits the student in relation to the other students you teach.

Outstanding

(Top 10%) Excellent Good Poor Not applicable

a. Academic motivation 4 3 2 1 N/A

b. Attitude towards homework 4 3 2 1 N/A

c. Study skills 4 3 2 1 N/A

d. Writing skills 4 3 2 1 N/A

e. Math skills 4 3 2 1 N/A

f. Intellectual curiosity 4 3 2 1 N/A

g. Willingness to try new activities 4 3 2 1 N/A

h. Time management 4 3 2 1 N/A

i. Ability to be a group leader 4 3 2 1 N/A

j. Class participation 4 3 2 1 N/A

k. Enthusiasm for class projects 4 3 2 1 N/A

l. Ability to work independently 4 3 2 1 N/A

m. Self-confidence 4 3 2 1 N/A

n. Ability to accept criticism 4 3 2 1 N/A

o. Contribution to positive spirit in your classroom

4 3 2 1 N/A

p. General level of maturity 4 3 2 1 N/A

q. Organization skills 4 3 2 1 N/A

r. Ability to interact with adults 4 3 2 1 N/A

I recommend this student to the Achieve program:

❏ With great enthusiasm ❏ With confidence ❏ With some confidence* ❏ With reservation* ❏ I do not recommend*

If any of the above options with an asterisk (*) were selected, please explain:

_______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________

Teacher’s Name ______________________________________________ Teacher’s Signature ________________________________________ Phone Number (__________) ____________ - ________________ Email: _________________________________________________________

TO THE TEACHER: THE STUDENT NAMED BELOW IS APPLYING TO ACHIEVE - A RIGOROUS TUITION-FREE ACADEMIC ENRICHMENT PROGRAM. ACHIEVE SEEKS

MOTIVATED, TALENTED STUDENTS TO PARTICIPATE IN OUR MULTI-YEAR PROGRAM, WHICH IS COMPRISED OF THREE SIX-WEEK SUMMER SESSIONS AND

SATURDAY SESSIONS DURING THE ACADEMIC YEAR. ACHIEVE IS COMMITTED TO SERVING LOW-INCOME MIDDLE SCHOOL STUDENTS WHO WOULD THRIVE IN A

COMMUNITY WHERE ACADEMIC AND SOCIAL STANDARDS ARE HIGH. ABOVE ALL, ACHIEVE SEEKS STUDENTS WHO WILL COMMIT TO ATTENDING ALL SESSIONS

AND WHO WILL WORK HARD! WE APPRECIATE YOUR CANDID RESPONSES AND THANK YOU FOR YOUR HELP IN THIS PROCESS.

PLEASE NOTE: THIS REFERENCE WILL BE KEPT CONFIDENTIAL AND SHOULD BE SUBMITTED DIRECTLY TO ACHIEVE BY THE TEACHER. REFERENCES SUBMITTED BY APPLICANTS WILL NOT BE ACCEPTED.

Return To: Achieve 10 Campus Drive Dedham, MA 02026 Student’s Name ______________________________________ Student’s School _________________________________________________ Teacher’s Name ________________________________________ Subject(s) _______________________________________________________

Does the student currently have an IEP? ❏ Yes ❏ No

1. Please describe this student’s academic performance, conduct, and effort in your class. 2. Does the student have difficulty grasping new concepts and retaining information? Does he/she seek help when needed? 3. Do the student’s grades truly reflect his/her academic ability? If not, where is the disconnect between the student’s grades and ability? 4. The Achieve program is a very rigorous academic environment. How do you think this student will respond to high academic and behavioral standards? 5. How could Achieve benefit this student? If accepted, what might this student contribute to the program?

PART 6B: Additional Teacher Reference (recommended)

Please circle the response that best suits the student in relation to the other students you teach.

Outstanding

(Top 10%) Excellent Good Poor Not applicable

a. Academic motivation 4 3 2 1 N/A

b. Attitude towards homework 4 3 2 1 N/A

c. Study skills 4 3 2 1 N/A

d. Writing skills 4 3 2 1 N/A

e. Math skills 4 3 2 1 N/A

f. Intellectual curiosity 4 3 2 1 N/A

g. Willingness to try new activities 4 3 2 1 N/A

h. Time management 4 3 2 1 N/A

i. Ability to be a group leader 4 3 2 1 N/A

j. Class participation 4 3 2 1 N/A

k. Enthusiasm for class projects 4 3 2 1 N/A

l. Ability to work independently 4 3 2 1 N/A

m. Self-confidence 4 3 2 1 N/A

n. Ability to accept criticism 4 3 2 1 N/A

o. Contribution to positive spirit in your classroom

4 3 2 1 N/A

p. General level of maturity 4 3 2 1 N/A

q. Organization skills 4 3 2 1 N/A

r. Ability to interact with adults 4 3 2 1 N/A

I recommend this student to the Achieve program:

❏ With great enthusiasm ❏ With confidence ❏ With some confidence* ❏ With reservation* ❏ I do not recommend*

If any of the above options with an asterisk (*) were selected, please explain:

_______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________

Teacher’s Name ______________________________________________ Teacher’s Signature ________________________________________ Phone Number (__________) ____________ - ________________ Email: _________________________________________________________

Return To: Achieve 10 Campus Drive Dedham, MA 02026 (781) 320-1329 fax Student’s Name _________________________________________ Student’s School __________________________________________________

TO BE COMPLETED BY PARENT/GUARDIAN:

CONSENT TO RELEASE ACADEMIC INFORMATION

In order to assist the Achieve staff in developing a clear view of my child’s academic ability and social progress in school, I hereby

authorize the release of complete school records and transcripts for my child, _____________________________________________,

to Achieve at Noble and Greenough School. Thank you.

________________________________________________________ Parent/Guardian’s Signature ________________________________________________________ Date

TO THE PRINCIPAL/COUNSELOR/TEACHER: The student named above is applying to Achieve - a rigorous tuition-free academic enrichment program. Achieve seeks motivated, talented students to participate in our multi-year program, which is comprised of three six-week summer sessions and Saturday sessions during the academic year. Achieve is committed to serving low-income middle school students who would thrive in a community where academic and social standards are high. Above all, Achieve seeks students who will commit to attending all sessions and who will work hard!

Please attach complete transcripts including:

o Report card grades for 5th and 6th grade o Standardized test scores o Attendance records

NOTE: THIS INFORMATION WILL BE KEPT CONFIDENTIAL AND SHOULD BE SUBMITTED DIRECTLY TO ACHIEVE BY A SCHOOL OFFICIAL. TRANSCRIPTS SUBMITTED BY APPLICANTS WILL NOT BE ACCEPTED.

If you have any questions regarding the program, please feel free to contact the Achieve office. Email: achieve@nobles.edu

Phone: 781-320-7125

Additional forms and information may be downloaded from our website: www.nobles.edu/achieve

Student’s Name

PART 7: Release Form