Program Application Due to C5 Georgia: November 20, 2015

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1 Program Application Due to C5 Georgia: November 20, 2015 A complete application must include: Complete Program Application Essay Recommendation Forms A & B Most Recent Report Card Student Information Student Name (First MI Last) Date of Birth Sex Race Please check all that apply (Optional) African American Asian Caucasian Hispanic Other: Primary Language Spoken at Home English Spanish Other: Current Middle School Female Male Cell Phone Number Parent/Guardian Information (1 st Emergency Contact) Parent/Guardian Name (First Last) Relationship to Student Occupation Highest Level of Education Elementary School Middle School Some High School High School Graduate/GED Technical/Trade School Some College Associates Degree Bachelor s Degree Master s Degree PhD/Advanced Graduate Work Home Address City Zip County Cell Phone Number Alternate Phone Number Additional Adults Living in Home Adult Name (First Last) Relationship to Student Occupation Highest Level of Education Elementary School Middle School Some High School High School Graduate/GED Technical/Trade School Some College Associates Degree Bachelor s Degree Master s Degree PhD/Advanced Graduate Work Cell Phone Number Adult Name (First Last) Relationship to Student Occupation Highest Level of Education Elementary School Middle School Some High School High School Graduate/GED Technical/Trade School Some College Associates Degree Bachelor s Degree Master s Degree PhD/Advanced Graduate Work Cell Phone Number Page 1

2 Student Name Date of Birth Family Housing Information Type of Housing In Which Family Lives Public Housing Apartment Rent Home Own Home Other: Financial Disclosure Application will not be considered if not complete C5 Georgia Youth Foundation programs are extended to youth from families that lack resources for quality enrichment experiences like those offered by C5 Georgia. Income and other financial considerations are a factor in determining eligibility and in the selection of youth. Reporting your family income is required. All information is strictly confidential. Total Number of People Living in the Home Total Annual Family Income Does the applicant qualify for free or reduced school lunch? $ No C5 Georgia Youth Foundation Participation Agreements To be Completed by Parent/Guardian Support of Student Application I understand that C5 Georgia Youth Foundation provides a 5-year leadership development program No that includes up to four weeks of overnight camp each summer and 3 4 required events throughout the school year. I support my student s application to the C5 Georgia Youth Foundation. Applicant Interviews All candidates may not be interviewed. A C5 Georgia representative will contact the nominator and the parent/guardian of the student if they have been invited to interview in early January. Interviews last hours; the interview schedule will be published when students are notified of interview. Interviews consist of two parts. The firs is a one-on-two interview involving the student, a C5 Georgia staff member and a C5 Georgia volunteer. The student will be asked questions regarding their personality and experiences in school and in the community. The second part involves working I a group with other young people. A C5 Georgia facilitator will lead group games and problem solving activities. The group session is active but does not involve sports or athletic activities. Sturdy shoes are recommended. While unlikely, because the group interviews are active, minor injuries such as those that might be caused by bumping into another person are possible. No I give permission for my student to participate in the C5 Georgia interview process. Consent to use Films and Photographs I give permission to the C5 Georgia Youth Foundation to use films and photos of my student during No the interview process for identification purposes as well as to promote C5 Georgia. This includes appearances in brochures, blog stories, and other media. Permission to Access Grade Reports I grant permission to C5 to access my child s grade reports and attendance records through his/her No school. My child s report card may be photocopied. I understand this is for the purpose of assessing C5 Georgia s impact on academic performance. Parent/Guardian Commitment Parent/Guardian Signature Required If my student is selected to participate in C5 Georgia Youth Foundation, I agree to attend 1 2 parent meetings each year. I understand that I am responsible for transporting to 3 4 events during the school year. I also understand that C5 Georgia requires youth to perform 250 hours of community service during the 5-year commitment, and must maintain a minimum 2.5 GPA to continue participating in C5 Georgia activities. Parent/Guardian Signature Date Page 2

3 Student Name Date of Birth School Experiences This section must be completed by the applicant Why do you want to be a leader? What extra-curricular activities or organizations are you involved with regularly? How do you spend your time after school? List eight (8) words that others might use to describe you. Have you had any special challenges in school or at home this year? If yes, please explain. Essay Instructions Must be written or typed on separate paper Essay Topic: Describe the most difficult experience in your life. What happened? How did you overcome this situation? What did you learn about yourself fin the process? How have you grown form it? Use your best effort when writing your essay, it is a very important part of your application. Applications without essays will not be considered. Essays should be 1 2 pages in length. Type your essay if possible; use additional pages as needed. Student Commitment Student Signature Required By signing this document, I am expressing my interest in being part of the C5 Georgia Youth Foundation program. I understand that C5 Georgia is a leadership development program and I want to be a positive leader in my community. If I am selected, I am prepared to attend up to four weeks of camp each summer and 3 4 events during the school year. I understand that I am expected to perform 250 hours of community service during the 5-year commitment, and must maintain a minimum 2.5 GPA. Applicant Signature Date Page 3

4 Student Name Date of Birth SUBMISSION INSTRUCTIONS You must attach your essay and most recent grade report to be considered for admission to C5 Georgia. Recommendations are collected electronically. Grade Report Attach a copy of your most recent grade report. If your GPA is below 2.5 (on a 4-point scale), you must submit one extra letter of recommendation from a non-family member describing your involvement in positive community activities. Recommendation Forms A and B Two recommendations must be completed by two different recommenders who know you well and can describe why you are a good candidate for C5 Georgia s leadership program. Coaches, teachers, mentors, counselors, pastors and youth leaders are excellent choices to complete recommendations. Recommendations should not come from immediate family members or from the person that nominated you. Recommendations are collected electronically and can be found at: A https://www.surveymonkey.com/r/recommendationa B https://www.surveymonkey.com/r/recommendationb You may use the included letters to ask for recommendations, or you may write your own. Please return this completed application, along with the supporting documents to your nominator. All applications are due to C5 Georgia by November 20, LATE OR INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED. Page 4

5 2500 Windy Ridge Parkway Atlanta, GA c5georgia.org Dear trusted mentor, A student,, who attends Middle School, is applying to be a part of C5 Georgia Youth Foundation s 5-year leadership development program. C5 Georgia Youth Foundation works to close the gap between income and achievement for Georgia students by transforming the lives of high-potential youth from challenged environments, empowering them to lead themselves and their communities. Our vision is for 100% of Georgia teens to graduate from high school. This student has taken the first step toward that vision by applying to be a part of our program. Along with their application, they must submit to us an essay, their current grades and two recommendations from community leaders like yourself. Our recommendations are completed online and are strictly confidential. Please fill out a recommendation regarding the above referenced student on or before November 20, You can find the online form at: https://www.surveymonkey.com/r/recommendationa Within forty-eight business hours of completing the recommendation, you will receive an from a C5 Georgia staff member confirming receipt of your recommendation. If you have questions about the C5 Georgia program, please visit our website (www.c5georgia.org) or you may contact me via phone ( ) or Thank you for taking the time to complete this recommendation. By doing so, you are recognizing this young person as a positive contributor in your community. In addition, for those who are selected for the C5 Georgia program, you are introducing them to the opportunity of a lifetime. Thank you, again! Earnest Womack Community Action Program Director C5 Georgia Youth Foundation Live to Lead.

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7 2500 Windy Ridge Parkway Atlanta, GA c5georgia.org Dear trusted mentor, A student,, who attends Middle School, is applying to be a part of C5 Georgia Youth Foundation s 5-year leadership development program. C5 Georgia Youth Foundation works to close the gap between income and achievement for Georgia students by transforming the lives of high-potential youth from challenged environments, empowering them to lead themselves and their communities. Our vision is for 100% of Georgia teens to graduate from high school. This student has taken the first step toward that vision by applying to be a part of our program. Along with their application, they must submit to us an essay, their current grades and two recommendations from community leaders like yourself. Our recommendations are completed online and are strictly confidential. Please fill out a recommendation regarding the above referenced student on or before November 20, You can find the online form at: https://www.surveymonkey.com/r/recommendationb Within forty-eight business hours of completing the recommendation, you will receive an from a C5 Georgia staff member confirming receipt of your recommendation. If you have questions about the C5 Georgia program, please visit our website (www.c5georgia.org) or you may contact me via phone ( ) or Thank you for taking the time to complete this recommendation. By doing so, you are recognizing this young person as a positive contributor in your community. In addition, for those who are selected for the C5 Georgia program, you are introducing them to the opportunity of a lifetime. Thank you, again! Earnest Womack Community Action Program Director C5 Georgia Youth Foundation Live to Lead.

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