Roxbury Prep Admission Application Form

General Information

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 ________________________________________________________________________________________________________________________ First Name Middle Name Family Name Preferred Name or Nickname ________________________________________________________________________________________________________________________ Home Address City State Country Zip/Postal Code

â?? Male â?? Female

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

________________________________________________________________________________________________________________________ E-Mail Address ________________________________________________________________________________________________________________________ Home Telephone (include area code) ________________________________________________________________________________________________________________________ Month / Year of Proposed Entrance Current grade Applying for Grade

Family Information - Parent/Guardian (1) ________________________________________________________________________________________________________________________ Name Relationship to Applicant ________________________________________________________________________________________________________________________ Home Address City State Country Zip/Postal Code ________________________________________________________________________________________________________________________ Home Telephone (include country, city, and area codes) Cell Telephone (include country, city, and area codes) ________________________________________________________________________________________________________________________ E-Mail Address Occupation Name of Company ________________________________________________________________________________________________________________________ Business Address City State Country Zip/Postal Code

Family Information - Parent/Guardian (2) ________________________________________________________________________________________________________________________ Name Relationship to Applicant ________________________________________________________________________________________________________________________ Home Address City State Country Zip/Postal Code ________________________________________________________________________________________________________________________ Home Telephone (include country, city, and area codes) Cell Telephone (include country, city, and area codes) ________________________________________________________________________________________________________________________ E-Mail Address Occupation Name of Company ________________________________________________________________________________________________________________________ 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

Check if appropriate: ❐Father deceased ❐Mother deceased

❐Both

❐Other _____________________________________________

❐Parents divorced ❐Parents separated

❐Father remarried ❐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) ____________________________________________________________________________________________________________ Name Age School ____________________________________________________________________________________________________________ Name Age School ____________________________________________________________________________________________________________ Name Age School ____________________________________________________________________________________________________________ Name Age School Present School Roxbury Preparatory Charter School School Name 120 Fisher Avenue Address

_______________

Roxbury City

MA State

___________________________________________________ Dates of Attendance USA Country

02120 _ Zip/Postal Code

______________________________________________617-566-2361 Ext______________________________________ High School Placement Counselor Telephone Fax Number Other schools attended in the past three years ____________________________________________________________________________________________________________ School Name City State Dates of Attendance ____________________________________________________________________________________________________________ School Name City State Dates of Attendance Signatures ____________________________________________________________________________________________________________ Signature of Applicant Date ____________________________________________________________________________________________________________ Signature of Parent or Guardian Date

Applicant Questionnaire

ADMISSION APPLICATION FORM ____________________________________________________________________________________________________________ Name of student Current grade ____________________________________________________________________________________________________________ Current School Applying for grade ____________________________________________________________________________________________________________ Home Address Street/PO Box City ____________________________________________________________________________________________________________ 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. ____________________________________________________________________________________________________________ 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. ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________

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. ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________

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

Applicant Questionnaire Name of student ______________________________________________________ 4. What book or other reading have you enjoyed the most in the past year? ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________

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

Applicant Questionnaire 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 ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________

Applicant Questionnaire

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?

â?? Boarding

â?? Day

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

Parent/Guardian Confidentiality Waiver

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. _______________________________________________________________________________________________________________________________

Name of parent or guardian ________________________________________________________________________________________________________________________ Signature of parent or guardian Date

Literacy Teacher Recommendation 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 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

Please provide any additional comments below: ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________

Signature of teacher

Date

Mailing address

Date

( Email address

Telep hone

)

High School Placement 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. ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________

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 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.

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

Please provide any additional comments below: ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________

Signature of teacher

Date

Mailing address

Date

( Email address

Telep hone

)

STEM Teacher Recommendation 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.

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

Please provide any additional comments below: ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________

Signature of teacher

Date

Mailing address

Date

( Email address

Telep hone

)