Download pdf - Roxbury Prep Admission Application Form

ADMISSION APPLICATION FORM Instructions: Carefully and legibly complete this form in blue or black ink and submit it to your Roxbury Prep High School Placement

Counselor so that they can submit it to the schools to which you want to apply for admission. After you have completed this form, fill out the

student questionnaire.

Applicant Information

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First Name Middle Name Family Name Preferred Name or Nickname

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Home Address City State Country Zip/Postal Code

❐ Male ________________________________________________________________________________________________________

❐ Female Age Date of Birth (Mo/Day/Year) Country of Birth Country of Citizenship

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E-Mail Address

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Home Telephone (include area code)

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Month / Year of Proposed Entrance Current grade Applying for Grade

Family Information - Parent/Guardian (1)

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Name Relationship to Applicant

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Home Telephone (include country, city, and area codes) Cell Telephone (include country, city, and area codes)

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E-Mail Address Occupation Name of Company

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Business Address City State Country Zip/Postal Code

Family Information - Parent/Guardian (2)

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Name Relationship to Applicant

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Home Telephone (include country, city, and area codes) Cell Telephone (include country, city, and area codes)

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E-Mail Address Occupation Name of Company

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Business Address City State Country Zip/Postal Code

General Information

Name of student ______________________________________________________

Applicant lives with? ❐Parent/Guardian 1 ❐Parent/Guardian 2 ❐Both ❐Other____________________________________

Where should admission materials be sent? ❐Parent/Guardian 1 ❐Parent/Guardian 2 ❐Both ❐Other__________________

Who is financially responsible for the candidate and who will pay the school bills?

❐Parent/Guardian 1 ❐Parent/Guardian 2 ❐Both ❐Other _____________________________________________

Check if appropriate: ❐Father deceased ❐Parents divorced ❐Father remarried

❐Mother deceased ❐Parents separated ❐Mother remarried

If parents are divorced or separated, who has legal custody of the applicant? ___________________________________________

Are you applying for financial aid? ❐ Yes ❐ No

List any admission tests you have taken _________________________________________________________________________

First language, other than English___________________________ Language spoken in the home __________________________

Race/Ethnicity (optional): How do you identify yourself?_____________________________________________________________

Information about brothers and sisters (use additional sheets if necessary)

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Name Age School

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Name Age School

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Name Age School

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Name Age School

Present School

Roxbury Preparatory Charter School _______________ ___________________________________________________

School Name Dates of Attendance

120 Fisher Avenue Roxbury MA USA 02120 _

Address City State Country Zip/Postal Code

______________________________________________617-566-2361 Ext______________________________________

High School Placement Counselor Telephone Fax Number

Other schools attended in the past three years

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School Name City State Dates of Attendance

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School Name City State Dates of Attendance

Signatures

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Signature of Applicant Date

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Signature of Parent or Guardian Date

General Information

ADMISSION APPLICATION FORM

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Name of student Current grade

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Current School Applying for grade

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Home Address Street/PO Box City

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School State Country Zip/Postal Code

Instructions:

■ Complete this form carefully and legibly in your own handwriting and submit it to your Roxbury Prep High School Placement Advisor to send

to the schools to which you want to apply. Use additional sheets, if necessary.

■ You may submit signed photocopies of this form.

■ Some schools may ask you to submit additional information. If you have questions about the admission process, please contact the High

School Placement Office.

All of the information included in this application is accurate to the best of my knowledge. I understand that providing inaccurate

information may result in the application being withdrawn or the student being dismissed.

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Student’s Signature Date

1.List and describe your level of interest and participation in school activities (school, volunteer groups, athletics, music, etc.).

List any awards or honors you received in the past two years. If you have one, please include your résumé along with this form.

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Applicant Questionnaire

Name of student ______________________________________________________

2. List and describe your level of interest and participation in hobbies, activities, and groups not associated with school (this can

include summer activities). List any awards or honors you received in the past two years.

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3. Which of your extracurricular activities or hobbies has been the most important to you? Please explain.

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Name of student ______________________________________________________

4. What book or other reading have you enjoyed the most in the past year?

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5. What else would you like high schools to know about you?

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Name of student ______________________________________________________

6. Please choose one of these statements and then type a 250-500 word response to it. Use additional sheets if necessary.

6a. Describe a person you admire or who has influenced you a great deal.

6b. What strengths will you bring to high school that will enhance the student body and learning atmosphere? (Be sure

to include the qualities you like best about yourself.)

6c. Explain the impact of an event or activity that has created a change in your life or in your way of thinking

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ADDITIONAL BOARDING SCHOOL SUPPLEMENT Instructions: If you are applying to an independent boarding school, please carefully and legibly complete this form and submit it to your

Roxbury Prep High School Placement Counselor so that they can submit them to the schools to which you want to apply for admission.

What resident status will you be applying for? ❐ Boarding ❐ Day

1. Why are you applying to boarding school and what do you hope to gain from attending one?

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ADMISSION APPLICATION FORM

Name of student ______________________________________________________

To the Parent/Guardian:

Please read and sign the statement below.

I, _______________________________, authorize the Roxbury Preparatory Charter School to release the transcript,

standardized test scores, and recommendation letters to the schools to which my child is applying. Additionally, I

acknowledge that I waive my right to read the confidential teacher recommendations and the school report for the

student listed below.

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Name of parent or guardian

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Signature of parent or guardian Date

Parent/Guardian Confidentiality Waiver

Literacy Teacher

RecommRecommendation

One of the

top few I

have ever

encountered

Excellent

(top 10%

this year)

Good

(above

average) Average

Below

average

No basis

for

judgment

Academic Potential Academic Achievement Intellectual Curiosity Effort/Determination Ability to Work Independently Organization Creativity Willingness to Take Intellectual Risks Concern for Others Honesty/Integrity Self-esteem Maturity (relative to age) Responsibility Respect Accorded by Faculty Respect Accorded by Peers Emotional Stability Overall Evaluation as a Person Overall Evaluation as a Student

Name of student ______________________________________________.

Please place check marks at the points that represent your evaluation of the student in comparison to other students in his or her age group

whom you have taught. If you have no fair basis for judgment, do not hesitate to say so

Please provide any additional comments below:

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Signature of teacher Date

Mailing address Date

( )

Email address Telephone

Literacy Teacher Recommendation

Name of student _________________________________________________________

The following materials will be submitted with this recommendation:

❐A school profile ❐ Standardized test scores

❐A graded writing assignment from the current term ❐Recent teacher reports, if any

❐A complete transcript including grades from 6th grade to the current term

How many students are in the entire grade? _____75_____

This candidate ranks _______ out of __75___ . _______ other students share this rank.

If the student is not, or has not been, in good academic standing, please explain.

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Has the student ever been dismissed, suspended, placed on probation, or received other serious disciplinary sanction?

❐ Yes ❐ No

Has he or she withdrawn from school voluntarily for an extended period of time for reasons other than health?

❐ Yes ❐ No

A note about the Roxbury Prep disciplinary system:

Roxbury Preparatory Charter School campuses provide safe and structured environment that promotes

students’ academic and social development. The disciplined environment is largely responsible for the

school’s academic success. Because we focus so much on small disciplinary issues each day, the larger

disciplinary issues are thereby eliminated. With this in mind, please know that suspensions at our school

should not be counted against students as they should at other schools.

A student may be suspended for:

- The use of any inappropriate language

- Throwing a piece of paper

- Any “play” fighting or contact of any kind

If you have any additional questions about the disciplinary system, please contact the Roxbury Prep High School

Placement Office at (617) 566-2361.

High School Placement Recommendation

One of the top few I have ever encountered

Excellent (top 10% this year)

Good (above average) Average

Below average

No basis for judgment


Literacy Teacher


Name of student ______________________________________________.


whom you have taught. If you have no fair basis for judgment, do not hesitate to say so.


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( )


High School Placement Recommendation

One of the top few I have ever encountered

Excellent (top 10% this year)

Good (above average) Average

Below average

No basis for judgment


Literacy Teacher


Name of student ______________________________________________.


whom you have taught. If you have no fair basis for judgment, do not hesitate to say so.


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STEM Teacher Recommendation