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College Track Sacramento
Enrollment Application
Applicant’s Name:____________________________
APPLICATION CHECKLIST
PRIORITY REVIEW DEADLINE: Friday, May 8, 2015 by 5:00pm
Before submitting your application, please ensure that you have completed each section and
provided corresponding paperwork as needed. Please note that incomplete applications will
not be considered.
! Section 1: Student Information
! Middle School Grades Attached
! Section 2: Parent Information (English or Spanish)
! Proof of Income Attached
! Section 3: Release of Confidential Information (English or Spanish)
! Section 4: Written Responses
! Teacher Letter of Recommendation
For priority review and selection, submit your completed application to the Operations
Manager at College Track , 3428 3rd Avenue, Sacramento 95817, by Friday May 8, 2015.
Please note your Sacramento Charter High School Admissions Lottery Application is also due
on April 24, 2015 by 4:30pm to the Sac High main office.
Should any questions come up during the application process, please feel free to contact us.
Thomas Munoz
Site Director
[email protected]
(916) 996-5514
Amber Busby
Operations Manager
[email protected]
(916) 287-8624
Detach this page and keep it for your records
College Track Sacramento
Enrollment Application
Applicant’s Name:____________________________
IMPORTANT DATES
April 24
Sacramento High School Application
Deadline
April 29
Parent Information Night
College Track Center
3428 3rd Avenue, Sacramento 95817
6:00pm – 7:00pm
May 8
Final Application Deadline
May 8, 9, 16
Interviews Conducted
Late May
Decision Letters Sent Home
June 11
Student & Parent Mandatory Orientation
July 7 – July 31
Mandatory ASAP Summer Program
Please note that all dates are tentative and subject to revision
Detach this page and keep it for your records
College Track Sacramento
Enrollment Application
Applicant’s Name:____________________________
Section 1: Student Information Form
Complete all information in this section. If any information is unknown or does not apply to
the student at this time, please write “N/A”.
_____________________________________________________________________________________
First Name
Middle Initial
Last Name
_________________________________________
Date of Birth
Ethnic Background:
! African American
! Asian-Pacific Islander
! Latino/a
! Multiracial
! Native American
! Caucasian
! Other: ________________________________
Place of Birth:
! United States
! Other: ________________________________
Citizenship:
! United States
! Permanent Resident
! Other
Gender:
! Female
! Male
_____________________________________________________________________________________
Street Address
City
Zip Code
_____________________________________
Student Cell Phone Number
_____________________________________
Student E-mail Address
Are you a ward of the court?
! Yes
! No
Do you have a disability?
! Yes
! No
Middle School:
! Ps7
! Oak Park Prep Academy
! Other: ________________________________
What is your current middle school GPA?
* Please attach a copy of
.
your most recent report
card. Application is considered incomplete
without this information. *
Extracurricular Activities/Sports:
College Track Sacramento
Enrollment Application
Applicant’s Name:____________________________
Section 2: Parent Information
All information in this section is to be completed by the parent/guardian of the College Track
student applicant. Your information will remain confidential and be on file at College Track.
Primary Parent/Guardian
Secondary Parent/Guardian
! Relationship________________________
! Did not start or finish high school
! High school degree
! Vocational school degree
! Some college (currently enrolled)
! Some college (not currently enrolled)
! 2 year college degree
! 4 year college degree
! Graduate degree
! Relationship________________________
! Did not start or finish high school
! High school degree
! Vocational school degree
! Some college (currently enrolled)
! Some college (not currently enrolled)
! 2 year college degree
! 4 year college degree
! Graduate degree
! No
! Yes, a little
! Yes, can handle most situations
! Yes, very well
! No
! Yes, a little
! Yes, can handle most situations
! Yes, very well
Name
Phone
number
Email
Address
Student
Lives With
Highest
education
level
English
fluency
Employment
! Full time
! Full time
(Occupation: _________________________) (Occupation: _________________________)
! Part time
! Part time
(Occupation: _________________________) (Occupation: _________________________)
! Not working
! Not working
! Disabled
! Disabled
How many members are in your household? _________
What is the combined household income?
! Less than $9,999
! Between $10,000 and $19,999
! Between $20,000 and $29,999
! Between $30,000 and $49,999
! Between $50,000 and $69,999
! More than $70,000
Please attach a W2 or a paystubs as proof of
income. Application is considered incomplete
without income verification.*
College Track Sacramento
Enrollment Application
Applicant’s Name:____________________________
Sección 2: Información de padres
Toda la información proporcionada en esta sección debe ser completada por el padre o
guardián. La información permanecerá confidencialmente en la propiedad del programa
College Track.
Padres Primaria / Tutor
Padres Secundaria / Tutor
Nombre
Número de
teléfono
Correo
electronico
El estudiante
vive con
Nivel de
educación
¿Hable
inglés?
Empleo
! Relación ________________________
! Relación ________________________
! No empezó o completo la secundaria
! No empezó o completo la secundaria
! Diploma de escuela secundaria
! Diploma de escuela secundaria
! Diploma de escuela vocacional
! Diploma de escuela vocacional
! Algo de estudio superior (actualmente
! Algo de estudio superior (actualmente
matriculado)
matriculado)
! Algo de estudio superior (no
! Algo de estudio superior (no
actualmente matriculado)
actualmente matriculado)
! Diploma de estudio superior (2 años)
! Diploma de estudio superior (2 años)
! Licenciatura universitaria (4 años)
! Licenciatura universitaria (4 años)
! Título de posgrado
! Título de posgrado
! No
! No
! Sí, un poco
! Sí, un poco
! Sí, puedo hablarlo la mayoría del
! Sí, puedo hablarlo la mayoría del
tiempo
tiempo
! Sí, muy bien
! Sí, muy bien
! Tiempo completo
! Tiempo completo
(Profesión: ___________________________) (Profesión: ___________________________)
! Parte de tiempo
! Parte de tiempo
(Profesión: ___________________________) (Profesión: ___________________________)
! No estoy trabajando
! No estoy trabajando
! Deshabilitado
! Deshabilitado
¿Cuántos miembros hay en su hogar? _________
Los ingresos anual?
! Menos de $9,999
! Entre $10,000 y $19,999
! Entre $20,000 y $29,999
! Entre $30,000 y $49,999
! Entre $50,000 y $69,999
! Más de $70,000
Adjunte una W2 o una recibos de pago como
prueba de ingresos . La aplicación se considera
incompleto sin verificación de ingresos.*
College Track Sacramento
Enrollment Application
Applicant’s Name:____________________________
Emergency Information
Give the name, address and phone
number of someone (a relative or friend)
who does not live with you but can be
contacted in the event of an emergency.
_______________________________________
Name
_______________________________________
_______________________________________
Address
Información de emergencia
Dar el número del nombre, dirección y
teléfono de alguien (un amigo o pariente)
que no vive con usted, pero que puede ser
contactado en caso de emergencia. Un
número de teléfono es obligatorio!
_______________________________________
Nombre
_______________________________________
_______________________________________
Dirección
_______________________________________
Telephone Number
_______________________________________
Número de teléfono
_______________________________________
Relationship to student
_______________________________________
Relación a estudiante
Does your son/daughter have allergies?
! No
! Yes
_______________________________________
Please indicate what if applicable.
¿Su hijo/a tiene alergias?
! No
! Si
_______________________________________
Por favor indique su alergia(s).
Does your son/ daughter take
medication?
! No
! Yes
¿Su hijo/a toma algún medicamento?
! No
! Si
_______________________________________
Please indicate what if applicable.
_______________________________________
Por favor indique su alergia(s).
College Track Sacramento
Enrollment Application
Applicant’s Name:____________________________
Section 3. Release of Confidential Information to Authorized Persons/Organizations
COLLEGE TRACK SEEKS TO SERVE COMMITTED STUDENTS WHO ARE SERIOUSLY CONSIDERING COLLEGE.
STUDENTS WHO DEMONSTRATE READINESS FOR THE STRUCTURE AND SUPPORT WE PROVIDE WILL BE
CONSIDERED FOR COLLEGE TRACK SACRAMENTO.
College Track is a national college completion program that supports students from the
summer after 8th grade all the way to college graduation. College Track is an after school
program that helps students who have the motivation but lack the resources and support to
obtain a college education. We help our students succeed in successfully completing high
school, moving on to college, and graduating college. We provide tools and
opportunities needed to reach their potential: academic support, extracurricular activities,
community service, and assistance in all aspects of the college application process.
_________________________________________
_____________________________________________
Student’s Name* (Print)
Student’s Date of Birth (MM/DD/YYYY)
_________________________________________
Sacramento*Charter*High*School*
Middle School
High School
*
***********
__________________________________________
Student’s CA State ID #
__________________________________________
____________________________________________
Parent/Guardian Name
Parent/Guardian Signature
Promise of Confidentiality: This application and any information provided will securely remain the
confidential property of the College Track Program.
I. I hereby give permission for my child to participate in the activities of College Track. I have
read the information about College Track and I am in support of my child’s participation. I will
allow College Track to transport my child to and from College Track sponsored activities and
their office, located at High 3428 3rd Ave, Sacramento, CA 95817.
II. I hereby grant College Track and its legal representatives and assigns, the irrevocable and
unrestricted right to use and publish my child’s first name and initial to last name and all
image and personality rights, including film, photograph, tape or video reproduction
(together, “Materials”) in which my child may be included, for editorial, trade, advertising,
website marketing and any other purpose and in any manner and medium (now existing or
hereafter developed); to alter the same without restriction; and to copyright the same. I
hereby release College Track and its legal representatives and assigns from all claims and
liability relating to said Materials.
College Track Sacramento
Enrollment Application
Applicant’s Name:____________________________
Even if my student is not accepted into the College Track program,
III. I hereby authorize College Track to access data from the District as well as have access to
and make copies of my child’s high school records (grades, test scores, attendance,
enrollment) through the completion of high school and into post-secondary education.
IV. I further authorize College Track to request, share and use all information held by College
Track and its partners relating to me, with all higher education institutions and program
partners for the purposes of enhancing my chances of graduating from college. This
includes, but is not limited to, personal information (such as my name, mailing address, email
address and date of birth), high school and college academic information (such as my high
school courses, grades, test scores, college transcripts), financial information (such as any
scholarships, financial aid and grants awarded to me), my recorded image and voice, and my
applications, admissions, enrollment, attendance and academic status at higher education
institutions (together, “My Information”).
V. College Track monitors the progress of applicants and participants to better evaluate the
effectiveness of its high school and college program in light of its charitable mission. As part
of the monitoring process, College Track may share “My Information” with researchers and
funders. I understand that College Track will take appropriate steps designed to secure and
protect this information, to keep it confidential, and to prevent others from connecting it to
me. To the extent possible, except as set forth in this form, any information that could identify
me will be removed or changed before such information is shared with other researchers,
organizations, or institutions and before any research results are made public in an
aggregated form.
Any waiver, modification or amendment of this form will be effective only if acknowledged
and agreed to by College Track. Further, I understand that College Track will maintain a
record of this form, that I am entitled to request and receive a copy, and that I may wish to
make a copy of this form for my own records. This form will be governed by and construed in
accordance with the laws of the State of California.
College Track is a California Public Benefit organization (501(c)3).
Parent/Guardian Signature: _______________________________________________________
College Track Sacramento
Enrollment Application
Applicant’s Name:____________________________
Sección 3. Divulgación de información confidencial a personas/organizaciones autorizadas
COLLEGE TRACK BUSCA ESTUDIANTES COMPROMETIDOS QUE SERIAMENTE ESTÁN CONSIDERANDO LA
UNIVERSIDAD. ESTUDIANTES QUE ESTÁN LISTOS PARA LA ESTRUCTURA Y APOYO QUE NOSOTROS
PROPORCIONAMOS.
Que es College Track? College Track es un programa después de la escuela que ayuda a los
estudiantes que tienen la motivación pero no los recursos y el apoyo para obtener una
educación universitaria. Ayudamos a nuestros estudiantes tener éxito en la escuela
secundaria, a ser aceptados a la universidad y graduarse de la universidad. Proporcionamos
las herramientas y oportunidades necesarias para que realicen sus sueños: apoyo
académico, actividades extracurriculares, servicio comunitario, y asistencia en todos los
aspectos del proceso de aplicación a la universidad.
_________________________________________
_____________________________________________
Nombre del estudiante* (Imprima)
Fecha de nacimiento del estudiante (Mes/Día/Año)
__________________________________________
Sacramento*Charter*High*School*
Escuela de enseñanza media
Escuela secundaria
*
__________________________________________
Número de identificación escolar #
__________________________________________
Nombre de padre/madre
____________________________________________
Firma de padre/madre
Promesa de Confidencialidad: La aplicación y toda información adicional proporcionada será
propiedad confidencial de el programa College Track.
I. Por la presente doy permiso para que mi hijo/a participe en las actividades de College
Track. He leído la información sobre College Track y estoy a favor de la participación de mi
hijo/a. Yo permitiré que College Track transporte mi hijo/a a y desde actividades
patrocinados por College Track y su oficina, situado en 3428 3rd Ave, Sacramento, CA 95817.
II. Por la presente otorgo College Track y sus representantes legales y cesionarios, el derecho
irrevocable y sin restricciones, a usar y hacer público el primer nombre e inicial de apellido y
todos los derechos de imagen y personalidad, incluyendo reproducción de película,
fotografía, cinta o video (en conjunto, “Materiales”) que pueden incluir mi hijo/a, para
editorial, comercio, publicidad, marketing de sitio web y cualquier otro propósito y en
cualquier forma y medio (ahora existentes o desarrollados en el futuro); para alterar el mismo
sin restricción y tener derecho de autor del mismo.
College Track Sacramento
Enrollment Application
Applicant’s Name:____________________________
Por la presente, libero College Track y sus representantes y cesionarios de todo reclamo y
responsabilidad relacionada con dichos Materiales.
Aún si mi estudiante no es aceptado en el programa College Track,
III. Por la presente autorizo a College Track acceder datos del Distrito, así como tener acceso
a y hacer copias de los registros de la escuela secundaria de mi hijo/a (notas, resultados de
examen, asistencia, inscripción) hasta la finalización de la escuela secundaria y en la
universidad.
IV. También autorizo College Track a solicitar, compartir y usar cualquier información en
manos de College Track y sus compañeros relacionada a mí, con instituciones de enseñanza
superior y socios del programa para el fin de mejorar mis probabilidades de graduar de la
universidad. Esto incluye, pero no se limita a, información personal (tal como mi nombre,
dirección postal, dirección de correo electrónico y fecha de nacimiento), información
académica de la escuela secundaria y la universidad (tales como mis cursos, notas, resultados
de examen de la escuela secundaria, expedientes universitarios), información financiera (tal
como cualquier beca, ayuda financiera y subvención otorgada a mi), y mis solicitudes,
admisiones, inscripción, asistencia, y estado académico en instituciones de enseñanza
superior (en conjunto, "Mi información”).
V. College Track monitorea el progreso de los solicitantes y participantes para evaluar la
eficacia de su programa de escuela secundaria y universidad en vista de su misión caritativa.
Como parte del proceso de monitoreo, College Track podrá compartir "Mi información" con
los investigadores y los financiadores. Entiendo que la College Track tomará las medidas
apropiadas con el fin de asegurar y proteger esta información, para mantenerla confidencial,
y para evitar que otros la conecten a mí. En la medida de lo posible, excepto como se
establece en el presente formulario, cualquier información que pueda identificarme será
eliminado o cambiado antes de que dicha información se comparte con otros
investigadores, organizaciones o instituciones, y antes de que los resultados de la
investigación se hagan públicas en forma agregada.
Cualquier renuncia, modificación o enmienda de este formulario sólo será efectiva si es
reconocido y aceptado por College Track. Además, yo entiendo que College Track
mantendrá un registro de este formulario, que tengo derecho a solicitar y recibir una copia, y
que quizás podrá desear hacer una copia de este formulario para mis propios registros. Este
formulario será dirigido e interpretado de acuerdo con las leyes del Estado de California.
College Track es una organización de beneficio público (501(c)3)
Firma de padre/madre: _______________________________________________________
College Track Sacramento
Enrollment Application
Applicant’s Name:____________________________
Section 4: Written Responses
Please answer the writing prompt below with at least a 150-200-word response. Write neatly in print on the
lines below or you may submit a typed response along with this application.
1. Please share a time when you pushed yourself beyond what you or others thought was possible to
achieve. We want to gain a sense of who you are, what is important to you, and why you deserve to
join College Track.
College Track Sacramento
Enrollment Application
Applicant’s Name:____________________________
This page is intentionally blank.
College Track Sacramento
Enrollment Application
Applicant’s Name:____________________________
Teacher Letter of Recommendation
The student listed above is applying to join College Track. College Track is a national college
completion program designed to support students from the summer after 8th grade throughout college
graduation. We will accept 60 students for the incoming class and your recommendation helps to
provide key insights into the applicant’s character and abilities. Thank you in advance for your time.
______________________________________
___________________________________________
Name
Subject Taught & School You Teach At
______________________________________
___________________________________________
Telephone Number
Email Address
______________________________________
__________________________________________
Signature
Date
Please return this recommendation to the applicant in an
envelope signed over the seal .
1. Student sets goals and reaches them with diligence:
! Always
! Usually
! Sometimes
! Never
2. What motivates this student? What excites him/her?
______________________________________________________________________________
3. Student overcomes setbacks and obstacles:
! Always
! Usually
! Sometimes
! Never
4. How does this student react to disappointment or failure?
______________________________________________________________________________
______________________________________________________________________________
5. Student makes sacrifices to work hard for what s/he needs:
! Always
! Usually
! Sometimes
! Never
6. Student demonstrates strong academic work habits:
! Always
! Usually
! Sometimes
! Never
7. Do you have any other remarks regarding this student?
______________________________________________________________________________
______________________________________________________________________________