BURLINGTON COUNTY ALTERNATIVE SCHOOL Burlington County Special Services School District 1000 Briggs Road Suite 130 Mt.

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1 BURLINGTON COUNTY ALTERNATIVE SCHOOL Burlington County Special Services School District 1000 Briggs Road Suite 130 Mt. Laurel, NJ Application Process MIDDLE SCHOOL By following the instructions below, you will assist the staff of the Burlington County Alternative School in assessing applications and servicing students as expeditiously as possible. Please refer any questions to Bobbie Downs at or (609) , ext School Responsibilities Application for Admission: Please assist parent(s)/guardian(s) in completing all parts (including the STATE ID) of the application. Whenever this page is completed by students and/or parent(s)/guardian(s), it is often illegible, incomplete and/or inaccurate. Narrative Statement: This should be completed by the professional(s) most familiar with the student. Generally speaking, the more narrative statements we have, the more information we have, and the more likely we are to accept a candidate. Checklist of Specific Behaviors: Please complete as suggested in directions at top of checklist. Pertinent Records: Please attach the most recent report card, along with any other academic, disciplinary and immunization/medical records. If the student is classified as a special needs student, please include a complete and current IEP (including complete psychological, social and learning evaluations) and/or any details pertaining to PL 504 accommodations. Student Responsibility Student Essay: The directions to the student are clear. As this essay is also treated as one more indicator of the student s academic ability, it is imperative that the student completes this task without any outside assistance. Additionally, this provides an opportunity for the students to reflect on their current situation. Parental Responsibility Interview/Orientation: Once an application has been evaluated and an applicant deemed appropriate, BCAS will notify the student s parent(s)/guardian(s) to arrange for an interview and orientation to our school on Briggs Road in Mt. Laurel. Successful completion of this final step will lead to the student being placed in the first available opening. PLEASE SEND APPLICATIONS TO: Bobbie Downs Middle School Principal bdowns@bcsssd.k12.nj.us

2 Personal Information BURLINGTON COUNTY ALTERNATIVE SCHOOL- Middle School APPLICATION FOR ADMISSION First Name: Middle Initial: Last Name: REQUIRED: NJ Smart ID # Student Cell: Student Age: Date of birth: Place of birth: Sex: M F Race*: * 1. Black, not of Hispanic origin. 2. Hispanic. 3. Asian or Pacific Islander. 4. American Indian or Alaskan Native. 5. White, not of Hispanic origin. 6. Non-resident, alien Language other than English spoken at home: Applicant lives with: Home phone: Home address: Number and Street City State Zip Father s name: Father s employer: Work phone: Father s address: Cell or other phone: Mother s name: Mother s employer: Work phone: Mother s address: Cell or other phone: Names (and ages) of any siblings: REQUIRED: If student is living in a group home, treatment home, etc. and the BILLING DISTRICT is different, please provide the name of the parent/guardian, address, and phone numbers where they live. Name-Parent/Guardian: Address: Ph: Billing District Sending District Academic Information Home middle school: Grade: Original graduation year: Total credits accrued: Guidance Counselor: Person at school who knows applicant best: NJ ASK scores: LAL: M: S: Other standardized test scores: Other schools attended (and dates): Special education classification (where applicable): Case Manager: Outside counselor or therapist (where applicable): Other conditions worth noting (e.g., medications, custody issues, legal issues):

3 STUDENT ESSAY In the space provided below, as clearly and concisely as possible, develop a response to one of the three suggested topics. Your essay is another piece of information we use to consider your ability and suitability for our program. You may use a computer and/or attach pages, but it is not necessary. 1) Explain aspects of yourself that your teachers and/or parents have never understood. 2) Describe someone who you admire or who has influenced you. 3) Describe the biggest challenge in your life so far, and how did you (or how could you) handle this situation? Name of Student (printed)

4 The following NARRATIVE STATEMENT is made as justification for the nomination of as a candidate for admission to the Burlington County Alternative Middle School. Name of individual providing the above statement Title of individual providing the above statement

5 CHECKLIST OF SPECIFIC BEHAVIORS Referral of troubled students should be based upon behaviors that have actually been observed. In most cases, an isolated incident would not be grounds for referring a student to the Burlington County Alternative School. Generally, most students accepted by BCAS have demonstrated histories of inappropriate behavior. With this in mind, it is suggested that copies of this form be distributed to all teachers and other professionals who are familiar with the candidate, and that the referring professional collate their responses (in either numerical or tally form) on a single copy of this form and attach it to the remaining pages of the student s application. Be reminded that the information you write below becomes a record that is protected by Federal Law. Federal Regulations (42 CFR Part 2) prohibit any further disclosure. Student s Name: Grade: Referral Date: Referred by: PLEASE CHECK ALL RELEVANT ITEMS: ACADEMIC PERFORMANCE OTHER BEHAVIORS Decline in quality of work Inappropriate behavior day-to-day Declining grades Change in friends and/or peer group Incomplete work Sudden, unexplained popularity Work not handed in Mood swings Failing in this subject Seeks constant adult contact Seeks adult advice without a specific problem CLASSROOM PERFORMANCE Time disorientation Apparent changes in personal values Disruptive in class Depression Inattentiveness Defensiveness Lack of concentration Withdrawal; a loner; separateness from others Lack of motivation Other students express concern about student Sleeping in class Fantasizing; daydreaming Impaired memory Compulsive overachievement Extreme negativism Perfectionism Cutting class Difficulty in accepting mistakes Late to class Rigid obedience Defiance of authority; breaking rules Talks freely about drug use; bragging Frequently needs discipline Associates with known drug users Cheating Lying Fighting Excessive crying Throwing objects Poor hygiene Verbally abusive Dramatic attention getting Obscene language; gestures Unrealistic goals Sudden outbursts Irresponsibility, blaming, denying Vandalism Family problems (death, divorce, illness) Frequent visits to the nurse, counselor Frequently observed wandering halls Frequent visits to the lavatory Stealing Hyperactivity, nervousness Suicidal ideation Inappropriate sense of humor Possesses or exchanges large amounts or money Non-Involvement in activities Extreme dissatisfaction with school POSSIBLE ALCOHOL OR DRUG ABUSE - SPECIFIC BEHAVIORS Witnessed Suspected Selling; delivering Possession of alcohol, drugs Possession of drug paraphernalia Use of alcohol, drugs Intoxication Smelling of alcohol or other substance Glassy / Blood-shot eyes Needle marks Dreamy / Blank expression Trembling

6 BURLINGTON COUNTY ALTERNATIVE MIDDLE SCHOOL Burlington County Special Services School District 1000 Briggs Road Suite 130 Mt. Laurel, NJ RECORDS RELEASE Name: Date of Birth: Grade: Address: Change in Educational Placement to: Burlington County Alternative Middle School Reason: I do hereby authorize the sending school district to release all academic and health records concerning the above named student. Please include grades up to the time of withdrawal, standardized test scores and other pertinent data concerning this student. Parent/Guardian Signature Date