MODEL Scholars Program Summer Bridge Program June 20 th July 25

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1 This is your application for the Elizabeth City State University MODEL Scholars Program. To participate in the Program you must complete this application and also complete an application for admissions to the University. This application includes a Student Information Form, Writing Sample Form, an Academic and Community Recommendation Forms, and a Parental Support Form. All of these must be completed and submitted as a package before the April 30 th deadline. APPLICATION MATERIALS Student Information Form Student Writing Sample Academic Recommendation Form o Form should be completed by a teacher, guidance counselor or school administrator and placed by them in a SEALED envelope. Community Recommendation Form o Form should be completed by someone from your community (minister, youth group leader, community service leader, etc.) and placed by them in a SEALED envelope. Parental Support Form o Form should be completed and signed by parent or legal guardian. All items should be included in one package and mailed to the following address: MODEL Scholars Program Attention: Mr. Victor Neal Elizabeth City State University 1704 Weeksville Road 324 Pharmacy Building-Campus Box 986 Elizabeth City, North Carolina Students accepted into the program will be notified by June 1, 2015 Please note that all students must complete an ECSU application for admissions and that requires a $50.00 application fee.

2 STUDENT INFORMATION FORM - - Social Security # Student s Last Name Student s First Name Student s Middle Name Gender: Female Male Age of Birth Name [s] of Parent/Legal Guardian (mo/date/year) Home Mailing Address City State Zip Code Home Telephone Number Parent s Cell Number Parent s Address Student s Cell Number Student s Address Major Student s T-shirt size Student s Polo size GPA SAT/ACT Household Educational Level Did your Parents attend college? Yes No If yes, did they graduate? Yes No Did your Grandparents attend college? Yes No If yes, did they graduate? Yes No Is English the first language in your home? Yes No If no, list your primary language High School Information Name of High School Street Address City State Zip Code Name of High School Counselor Telephone Number Address I have already completed by application for admission to ECSU. My application was mailed, completed electronically or provided to an admissions representative on. () Office Use Only: MS Application Received ECSU Application Received () ()

3 STUDENT WRITING SAMPLE On a separate sheet of paper, using 12 point font, type an essay that answers the following questions. Please use complete sentences and check your grammar, punctuation and spelling. What do you know about Elizabeth City State University? What is your intended major? How will this program benefit you? What other information would you like to share? PLEASE READ CAREFULLY: I understand that the terms and conditions for participating in the MODEL Scholars Program. I also understand the time and effort required by me in order to successfully complete the summer bridge program. Student Signature Parent/Guardian s PRINTED NAME (circle mother/father/guardian/other : ) Parent/Guardian Signature

4 ACADEMIC RECOMMENDATION FORM NAME OF THE STUDENT PERSON COMPLETING THE REFERENCE RELATIONSHIP TO THE STUDENT Signature of Reference Phone Number Address To the Recommender: The student named above is applying for admission to the MODEL Scholars Program at ECSU. Please use this form to share with us your perceptions of how this student will meet the academic and social responsibilities of the Program. Please complete this form and return it to the student in a sealed envelope with your signature across the back, sealed portion of the envelope. Thank you for your assistance. Independence The student makes appropriate decisions and is not easily misguided by peers. Drive and Motivation The student is a self-starter and is inner driven to complete a task. Potential for Growth The student displays the necessary qualities for commitment to learning. Ability to follow Instructions The student follows directives and stays on task. Ability to follow Rules The student respects rules and regulations. Ability to work well in Groups The student works well as a member of a social and academic team. Writing Skills The student displays grade level writing skills. Place an (X) in one box, on each row that applies to the applicant. Excellent Good Average Below Average Have not observed Speaking Skills The student displays appropriate public speaking qualities. Capacity for Analytical Thinking The student can reason and draw conclusions when challenged. I would make the following recommendation for the applicant's admission to the program: Enthusiastically recommend Recommend Additional Information: Recommend with reservations Do not recommend

5 COMMUNITY RECOMMENDATION FORM NAME OF THE STUDENT PERSON COMPLETING THE REFERENCE RELATIONSHIP TO THE STUDENT Signature of Reference Phone Number Address To the Recommender: The student named above is applying for admission to the MODEL Scholars Program at ECSU. Please use this form to share with us your perceptions of how this student will meet the academic and social responsibilities of the Program. Please complete this form and return it to the student in a sealed envelope with your signature across the back, sealed portion of the envelope. Thank you for your assistance. Independence The student makes appropriate decisions and is not easily misguided by peers. Drive and Motivation The student is a self-starter and is inner driven to complete a task. Potential for Growth The student displays the necessary qualities for commitment to learning. Ability to follow Instructions The student follows directives and stays on task. Ability to follow Rules The student respects rules and regulations. Ability to work well in Groups The student works well as a member of a social and academic team. Writing Skills The student displays grade level writing skills. Place an (X) in one box, on each row that applies to the applicant. Excellent Good Average Below Average Have not observed Speaking Skills The student displays appropriate public speaking qualities. Capacity for Analytical Thinking The student can reason and draw conclusions when challenged. I would make the following recommendation for the applicant's admission to the program: Enthusiastically recommend Recommend Additional Information: Recommend with reservations Do not recommend

6 PARENTAL SUPPORT FORM I, (parent or guardian s name) do hereby acknowledge and affirm support of my student s, (student s name), application for the MODEL Scholar s Program at Elizabeth City State University. I am aware the MODEL Scholar s Program consists of an on campus summer bridge program aimed at preparing my student for academic success. I also understand that the summer bridge program provides five weeks of intensive academic instruction along with personal development and cultural enrichment activities. (These activities may require overnight travel.) I commit to: 1. Ensuring that my student will attend the entire five week session of the summer bridge program and reside on the campus of Elizabeth City State University in a MODEL Scholar learning community. 2. Ensuring that my student participates in subsequent activities during the academic year. 3. Providing my student with the family support needed each day to be successful at Elizabeth City State University. 4. Being available if needed to discuss my student s academic performance and to provide necessary encouragement and support. 5. Knowing that attendance and behavioral problems can lead to being dismissed from the program and from the University. Please provide any additional or necessary comments you which to make in the section below. Parent or Guardian s Name Signature Home Telephone Number Cell Number

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