APPLICATION MATERIALS Student Information Form Student

MODEL Scholars Program
Summer Bridge Program
June 20th –July 25
This is your application for the Elizabeth City State University MODEL Scholars Program. To participate in the Program
you must complete this application and also complete an application for admissions to the University. This application
includes a Student Information Form, Writing Sample Form, an Academic and Community Recommendation Forms, and
a Parental Support Form. All of these must be completed and submitted as a package before the April 30th deadline.
APPLICATION MATERIALS
Student Information Form
Student Writing Sample
Academic Recommendation Form
o Form should be completed by a teacher, guidance counselor or school
administrator and placed by them in a SEALED envelope.
Community Recommendation Form
o Form should be completed by someone from your community (minister,
youth group leader, community service leader, etc.) and placed by them in a
SEALED envelope.
Parental Support Form
o Form should be completed and signed by parent or legal guardian.
All items should be included in one package and mailed to the following address:
MODEL Scholars Program
Attention: Mr. Victor Neal
Elizabeth City State University
1704 Weeksville Road
324 Pharmacy Building-Campus Box 986
Elizabeth City, North Carolina 27909
Students accepted into the program will be notified by June 1, 2015
Please note that all students must complete an ECSU application for admissions and that requires a $50.00
application fee.
MODEL Scholars Program
Summer Bridge Program
June 20th –July 25
STUDENT INFORMATION FORM
_____-_____-________
Date
Social Security #
____________________________ _______________________ ____________________________
Student’s Last Name
Gender:
Female
Student’s First Name
Male
Student’s Middle Name
Age
Date of Birth
(mo/date/year)
Name [s] of Parent/Legal Guardian
Home Mailing Address City State Zip Code
Home Telephone Number
Parent’s Cell Number
Parent’s E-mail Address
Student’s Cell Number
Student’s E-mail Address
Major
Student’s T-shirt size
Student’s Polo size
GPA
Household Educational Level
Did your Parents attend college?
Yes
No
If yes, did they graduate?
Yes
No
Did your Grandparents attend college?
Yes
No
If yes, did they graduate?
Yes
No
Is English the first language in your home? Yes
No
SAT/ACT
If no, list your primary language
High School Information
Name of High School
Street Address
City
Name of High School Counselor
Telephone Number
State
Zip Code
E-mail Address
I have already completed by application for admission to ECSU. My application was mailed, completed electronically or provided to an
admissions representative on
.
(Date)
Office Use Only:
MS Application Received
ECSU Application Received
(Date)
(Date)
MODEL Scholars Program
Summer Bridge Program
June 20th –July 25
STUDENT WRITING SAMPLE
On a separate sheet of paper, using 12 point font, type an essay that answers the following questions. Please use complete
sentences and check your grammar, punctuation and spelling.
•
What do you know about Elizabeth City State University?
•
What is your intended major?
•
How will this program benefit you?
•
What other information would you like to share?
PLEASE READ CAREFULLY: I understand that the terms and conditions for participating in the MODEL Scholars
Program. I also understand the time and effort required by me in order to successfully complete the summer bridge
program.
Student Signature
Date
Parent/Guardian’s PRINTED NAME (circle mother/father/guardian/other :
Parent/Guardian Signature
)
Date
MODEL Scholars Program
Summer Bridge Program
June 20th –July 25
ACADEMIC RECOMMENDATION FORM
NAME OF THE STUDENT
PERSON COMPLETING THE REFERENCE
RELATIONSHIP TO THE STUDENT
Signature of Reference
Date
Phone Number
E-mail Address
To the Recommender: The student named above is applying for admission to the MODEL Scholars Program at ECSU. Please use
this form to share with us your perceptions of how this student will meet the academic and social responsibilities of the Program.
Please complete this form and return it to the student in a sealed envelope with your signature across the back, sealed portion of
the envelope. Thank you for your assistance.
Place an (X) in one box, on each row that applies to the applicant.
Excellent
Good
Average
Below Average
Independence
The student makes appropriate decisions and is not
easily misguided by peers.
Drive and Motivation
The student is a self-starter and is inner driven to
complete a task.
Potential for Growth
The student displays the necessary qualities for
commitment to learning.
Ability to follow Instructions
The student follows directives and stays on task.
Ability to follow Rules
The student respects rules and regulations.
Ability to work well in Groups
The student works well as a member of a social and
academic team.
Writing Skills
The student displays grade level writing skills.
Speaking Skills
The student displays appropriate public speaking
qualities.
Capacity for Analytical Thinking
The student can reason and draw conclusions when
challenged.
I would make the following recommendation for the applicant's admission to the program:
Enthusiastically recommend
Recommend
Recommend with reservations
Do not recommend
Additional
Information:
Have not observed
MODEL Scholars Program
Summer Bridge Program
June 20th –July 25
COMMUNITY RECOMMENDATION FORM
NAME OF THE STUDENT
PERSON COMPLETING THE REFERENCE
RELATIONSHIP TO THE STUDENT
Signature of Reference
Date
Phone Number
E-mail Address
To the Recommender: The student named above is applying for admission to the MODEL Scholars Program at ECSU. Please use
this form to share with us your perceptions of how this student will meet the academic and social responsibilities of the Program.
Please complete this form and return it to the student in a sealed envelope with your signature across the back, sealed portion of
the envelope. Thank you for your assistance.
Place an (X) in one box, on each row that applies to the applicant.
Excellent
Good
Average
Below Average
Independence
The student makes appropriate decisions and is not
easily misguided by peers.
Drive and Motivation
The student is a self-starter and is inner driven to
complete a task.
Potential for Growth
The student displays the necessary qualities for
commitment to learning.
Ability to follow Instructions
The student follows directives and stays on task.
Ability to follow Rules
The student respects rules and regulations.
Ability to work well in Groups
The student works well as a member of a social and
academic team.
Writing Skills
The student displays grade level writing skills.
Speaking Skills
The student displays appropriate public speaking
qualities.
Capacity for Analytical Thinking
The student can reason and draw conclusions when
challenged.
I would make the following recommendation for the applicant's admission to the program:
Enthusiastically recommend
Recommend
Recommend with reservations
Do not recommend
Additional
Information:
Have not observed
MODEL Scholars Program
Summer Bridge Program
June 20th –July 25
PARENTAL SUPPORT FORM
I, _____________________________________________(parent or guardian’s name) do hereby acknowledge
and affirm support of my student’s, ___________________________________(student’s name), application for the
MODEL Scholar’s Program at Elizabeth City State University. I am aware the MODEL Scholar’s Program consists of
an on campus summer bridge program aimed at preparing my student for academic success. I also understand that the
summer bridge program provides five weeks of intensive academic instruction along with personal development and
cultural enrichment activities. (These activities may require overnight travel.)
I commit to:
1. Ensuring that my student will attend the entire five week session of the summer bridge program and
reside on the campus of Elizabeth City State University in a MODEL Scholar learning community.
2. Ensuring that my student participates in subsequent activities during the academic year.
3. Providing my student with the family support needed each day to be successful at Elizabeth City State
University.
4. Being available if needed to discuss my student’s academic performance and to provide necessary
encouragement and support.
5. Knowing that attendance and behavioral problems can lead to being dismissed from the program and
from the University.
Please provide any additional or necessary comments you which to make in the section below.
Parent or Guardian’s Name____________________________ Signature ___________________________ Date_____________
Home Telephone Number_________________________ Cell Number ______________________________