COUNSELOR OR PRINCIPAL FORM Have your parent/guardian complete the COUNSELOR OR PRINCIPAL FORM and you take it to the school Counselor or Principal.

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1 STUDENT APPLICATION CHECKLIST Breakthrough Houston is a select program and you have been invited to apply. Welcome to the application process! We are thrilled that you are interested in applying to Breakthrough Houston (BTH). At BTH, middle-school students develop academic and leadership skills. All classes are taught by outstanding high-school and college students. Breakthrough Houston is FREE! Students make a commitment to attend the middle-school, six-week summer sessions and the School-Year Program for three years. Once you have moved on to high school, you become part of the Breakthrough Houston College Bound Program. The College-Bound Program is an additional four-year commitment where you will be supported in your preparation for college. In addition to the summer and school-year program, the college-bound program offers many opportunities for college preparation, job opportunities, and enrichment programs all over the country, as well as networking with college-bound high-school and college students. Participation in the College-Bound Program is part of the six year commitment to BTH. To fill out this application packet, you need to complete several steps. Please follow the directions carefully. We need all of this information to help us make an informed decision about whether BTH would be a good program for you. Use this checklist to help you complete your file. KEEP THIS PAGE and use it to make sure everything is turned in on time. Check off each step once it is complete. 1. STUDENT APPLICATION Complete the STUDENT STATEMENT, short answer questions 1 3, and the STUDENT ESSAY in your own handwriting. Be sure to use a blue or black pen, not pencil. We suggest you do a rough draft on a separate piece of paper and show it to an adult or older person before you fill out the final application. PLEASE ENCLOSE A SMALL PICTURE WITH THE APPLICATION. Application is due: Tuesday, February 17, COMMITMENT CONTRACT and AGREEMENT With signatures and addresses. 3. PARENT/GUARDIAN STATEMENT and INCOME STATEMENT Have your parent(s) or guardian(s) complete the PARENT SECTION, including the FREE AND REDUCED LUNCH Acceptance and include A COPY OF YOUR PARENT S INCOME TAX RETURN (1040) with your application COUNSELOR OR PRINCIPAL FORM Have your parent/guardian complete the COUNSELOR OR PRINCIPAL FORM and you take it to the school Counselor or Principal. TEACHER RECOMMENDATION FORMS Have your Math and English teachers complete the TEACHER RECOMMENDATION FORMS If you received this application at your school: DO NOT MAIL IT BACK! Return parts 1 4 to the Breakthrough Houston coordinator at your school. If you did not receive this application at your school: then mail it to the address below before 2/17/15 Application Deadline is February 17, 2015 Questions? Contact Ms. Heinzerling at or kheinzerling@sjs.org Breakthrough Houston, 2401 Claremont Ln. Houston, Tx

2 FREQUENTLY ASKED QUESTIONS What is Breakthrough Houston? Breakthrough Houston is a member of the Breakthrough Collaborative. It is a tuition-free, year-round academic program for promising middle- and high-school students from educationally underserved backgrounds. The program consists of school-year Saturday enrichment sessions and a six-week, intensive summer session, which begins the summer after a student s sixth grade year. After middle school, Breakthrough high-school students participate in a Saturday program which includes PSAT/SAT prep classes, career counseling, college trips and much more. Who are the Breakthrough students? Students just like you! Breakthrough students come from many different backgrounds. They share a love of knowledge and desire to go to college. Breakthrough students strive to do their best and are always open to new ideas. What kind of students apply to Breakthrough? Motivated 6 th graders are eligible to apply. You must have good behavior, above-average grades, and a strong desire to attend college-preparatory high schools and college after high school. Breakthrough students are willing to make a commitment to their education. They love learning and new challenges. Who are the Breakthrough teachers? All the teachers are exceptional high-school and college students who enjoy sharing their time and ideas with younger students. With the help of the program s directors, deans, and mentor teachers, the student-teachers make lesson plans that are fun and engaging. What is the cost? Breakthrough is tuition-free. There is NO COST to you or your family. Breakfast and lunch are also provided for free during the summer. The only cost is your 6 year commitment to the program. What is the commitment? This is a six-year program. Your personal and family commitments should be scheduled around Breakthrough for the first three years. Middle school students attend the School Year Program on Saturdays. 7 th, 8 th, and 9 th graders attend the summer program. Once you are in high school, we expect that you will be involved in activities at your school. But, we still have a Saturday program during the school year that includes tutoring, mentoring and informational seminars about summer jobs, interviewing skills, and the SAT/ACT! 2

3 How should I fill out the application? The application should be handwritten in pen, not pencil. You must complete the Student Application by yourself. Your parents have their own application. Remember to write a rough draft of your essays first, and then write the final draft on the application so that we can see your best writing. You will also need recommendations from your Math and English teachers. What happens after I apply? An admissions committee reviews the applications. You are required to take placement tests on Saturday, March 7, from 9AM to 11:30PM. Once a decision has been made, a letter will be mailed to you. Information about acceptance will not be given over the phone. What are classes like? A former Breakthrough student said, It s a program that will challenge your mind, while you have fun... Students take four core classes: Literature, Science, Math, and Writing. Along with our core curriculum, students take activities and electives. There are no more than twelve students per class so that students receive individual attention. All classes have hands on activities. Imagine dissecting a cow s eye, writing a newspaper, or holding a poetry slam! Are we in class all day? No! In the afternoon, students have an opportunity to explore new activities or ones they already enjoy. Past courses include Mock Trial, Film, Graffiti Art, Dance, Speech and Debate, and many more. There are also exciting field trips and special events, such as Olympics Day, Career Day and Service Learning. What about homework, tests, and grades? Homework and tests are essential to learning. On average, Breakthrough students complete two hours of homework a night during the Summer Program. The teachers design assignments and tests that are thoughtprovoking. There are no final grades. Instead, students receive written evaluations from their academic teachers. Is transportation provided? During the summer, bus transportation is provided for students living within HISD. You and your family are responsible for providing transportation to the School Year Program. Carpools are worked out for students who have a hard time getting to the SYP. Who gets accepted into Breakthrough? Admission to Breakthrough Houston is selective. The goal of the admissions committee is to select committed, motivated students who are economically disadvantaged and ethnically diverse. There is no specific quota per public school. You should not be upset if you do not get a space; instead, be proud that you took the risk to apply. When are applications due? February 17, 2015!! Applications received at school must be completed and returned to your school representative. If you received your application in the mail or on-line, please mail it back to the address below. We do NOT accept faxed copies. Deadline for all applications is: February 17, 2015 Breakthrough Houston 2401 Claremont Lane Houston, TX (713) Office kheinzerling@sjs.org 3

4 BTH STUDENT APPLICATION STUDENT NAME: DUE DATE: FEBRUARY 17, 2015 Complete this application in ink, not pencil If I am accepted I agree to: 1. Attend Three Summer Six-Week Programs During Middle School 2. Attend School-Year Saturday School 3. Attend the High-School Program 4. Attend Special Events 5. Maintain An Average of 80% Or Above In Every Core Class During The Academic Commitment Student Signature: STUDENT INFORMATION: Full Name: First Middle Last Home Address: Number & Street Apt. # City State ZIP Student Student cell number: Home Telephone: Social Security Number: Date of Birth: (Not having a SSN will not prevent you from being considered for admission into BTH.) Parents names: Parents Parents cell number(s): Has any member of your family ever participated in Breakthrough or Summerbridge? Is your answer is yes, please state the name and his/her relationship to you? If the answer is no, please tell us how you heard about Breakthrough. Ethnic Background: (Circle one) African-American American-Indian Asian Latino or Hispanic Middle Eastern Pacific Islander Southeast Asian White or Caucasian Other Multiracial (please indicate racial groups) Gender: (Circle one) Male or Female Is English your first language? If not, what language is? What language is spoken in your home? Do both parents live with you at home? If not, with which parent do you live? Which parent should we to talk about grades and progress in school? Elementary School Current School Grade Zoned School (if different) Type of school: (Circle one) Public or Private or Charter If you attend an HISD school, please give us your School ID number and Grade Speed information: Username Password School ID #: 4

5 BTH STUDENT APPLICATION DUE DATE: FEBRUARY 17, 2015 STUDENT NAME: ANSWER THE FOLLOWING QUESTIONS: (Please complete these questions in complete sentences. Do this section on your own. Write in blue or black ink.) 1. What are your favorite things to do outside of school (hobbies, special interests, etc.)? Why do you enjoy them? 2. If there was one life adventure you could experience, 1) what would you do and why, and 2) where would you go and why? Please answer all parts of the question. 3. What are three personal qualities/strengths, and how do you see those qualities as being important in your path to college? 5

6 BTH STUDENT APPLICATION DUE DATE: FEBRUARY 17, 2015 STUDENT NAME: STUDENT ESSAY Question: All of us face challenges in life. One challenge might be making new friends. Another might be learning how to play a sport or a musical instrument. Another might be a problem within your own family situation. In a well-developed composition, describe a challenge that you have faced. What lesson did you learn? Support your ideas with examples and details. To write this essay: 1) Write a rough draft first. 2) The essay should be 2-3 paragraphs. 3) On this section, it is okay to have someone check your essay for grammar and spelling, but the ideas, writing, and words should all be yours. 4) You have the space below to write your essay. You may attach additional sheets. 5) Write your final essay in blue or black pen. Show us your very best writing! 6

7 EXPRESS YOURSELF! Please use this box to tell us about yourself. Fill it up Use your creativity! Put anything here: drawings, poetry, math equations, write a rap, put in photos, write a song or anything else that expresses you. 7

8 6 YEAR Commitment Contract Breakthrough Houston makes a six-year commitment to your family, and we expect the same from you. Please review the Six-Year-Commitment Chart on the next page (yours to keep), and the expectation agreement below. If you agree to the commitments required, sign below. Expectation Agreement Breakthrough Houston uses the internet more and more each year. We find it s the quickest and most reliable way to communicate with students and families, and we re saving the environment! We require that each new family has at least one address and checks it at least once per week. Even if you do not have the internet or a computer at your home, it is available for free at schools, libraries, and possibly your place of employment. You can create a free account at yahoo.com; gmail.com; hotmail.com or many others. By signing below, you agree to maintain contact with us for the next six years. If your address (or any other contact information) should change, you will notify the BTH office so we can update your file. My family understands the commitment that we re making to Breakthrough Houston and that BTH is making to our family. We re committed to our success with the program and we ll do everything we can to uphold our end of the agreement. Student Name: Student Signature: Date: Parent(s) Signature(s): Date: Parent(s) Signature(s): Date: Current Address(es): Name: Name: Name: 8

9 BREAKTHROUGH HOUSTON PARENT OR GUARDIAN STATEMENT Student s Name Current School Grade Mother/Guardian/Madre Father/Guardian/Padre Name Name Address Address City State Zip City State Zip Home Phone Home Phone Mobile Phone Mobile Phone Address Address Occupation Occupation Business Name Business Name Business Phone Business Phone May we contact you at work? Yes No May we contact you at work? Yes No Ethnic Background Ethnic Background Please circle your highest level of education and give us what kind of degree you received. Please circle your highest level of education and tell us what kind of degree you received. Elementary school High School College Degree Middle school Trade School Post-graduate Degree Elementary school High School College Degree Middle school Trade School Post-graduate Degree Language spoken at home: Language spoken at home: Are parents (Circle one): Married Separated Divorced Single Parent With whom is your child living? Does your child receive free or reduced lunch? Yes No Household Income (Please check the correct box): Less than $10,000 $10,001 to $20,000 $20,001 to $30,000 $30,001 to $40,000 $40,001 to $50,000 $50,001 to $70,000 $70,001 and above * We need a copy of the following: 1. Free and Reduced Lunch acceptance (you can get that in the school office if you did not keep a copy) 2. A copy of your most recent tax return or 1040 form. 9

10 BREAKTHROUGH HOUSTON PARENT STATEMENT Page 2 Name of student applicant: A parent or guardian should answer the following questions: Names and ages of the applicant s siblings: Total number of members in your family Why do you want your son or daughter to be a part of Breakthrough Houston? What do you think are your son or daughter s strengths? What do you think are your son or daughter s weaknesses? Please tell us about your commitment to your son or daughter s education and how committed are you to making sure your son or daughter attends college? Will your family be able to fully commit to Breakthrough Houston for six years? (for three summers and the school year program during Middle School, and the four-year, High-School Program) Circle one: Yes Parent s signature: No 10

11 BREAKTHROUGH HOUSTON APPLICATION COUNSELOR OR PRINCIPAL FORM PARENTS: PLEASE COMPLETE THE TOP OF THIS FORM AND HAVE YOUR CHILD TAKE IT TO THE SCHOOL COUNSELOR OR PRINCIPAL TO GATHER MATERIALS BELOW Counselor or principal s name: Title: School: Child s name : Grade: is applying to the BREAKTHROUGH HOUSTON Program sponsored by HISD, Episcopal High School and St. John s School. BREAKTHROUGH HOUSTON is an academic enrichment, tuition-free, year-round college preparatory program. Sixth graders (and some seventh graders) from middle schools are eligible. Applications are due by February 17, 2015 PLEASE SEND COPIES OF THIS CHILD S: 1. MOST RECENT REPORT CARD 2. LATEST STANDARDIZED TEST SCORES (NOT STARR) 3. Verification of Qualification for Free or Reduced Lunch TO: BREAKTHROUGH HOUSTON 2401 CLAREMONT LANE HOUSTON, TX PLEASE NOTE: If you are one of the target schools, this information can be returned to the person designated by the principal and it will be picked up along with the student applications. Parent or Guardian Signature Date Questions? Contact Kathy Heinzerling; kheinzerling@sjs.org in the Breakthrough Houston Office: 11

12 English Teacher Recommendation Student s Name School Teacher s Name Subject(s) Taught Students: Write your name, school, teacher s name and the exact ENGLISH class he or she teaches you above. Then give this form to your ENGLISH teacher. Ask him or her to return it to you in a sealed envelope by February 8th. Return it in an envelope along with your application to your school representative or mail it to the Breakthrough Houston office by February 17th, (BTH, 2401 Claremont Ln. Houston, Tx 77019) Please circle the response that best suits the student, in relation to the student s peers. Academic No basis for Below Average Above Outstanding Judgment Average Average Academic motivation N Attitude towards homework N Study habits/organization N Writing skills N Reading skills N Problem-solving skills N Intellectual curiosity N Overall academic skills/aptitude N Personal Willingness to try new activities N Ability to be a group leader N Willingness to volunteer in class N Enthusiasm for class projects N Ability to work independently N Self-confidence N Reaction to criticism N Sense of humor N Concern for fellow students N General level of maturity N Creativity N Ability to work well with adults N Overall personal qualities N What special interests, talents, or abilities could this applicant contribute to BTH? Are there any social, academic, or behavioral challenges that this student faces? 12

13 Teacher Recommendation continued How could this student benefit from participating in BTH? Describe this student s attitude toward homework, studying, and academic achievement. How much effort does this student put into achieving his or her goals? Does this student work AT or ABOVE grade-level in your subject? BTH is a program for dedicated, hard-working, and motivated students who want to go to college. I recommend this student for the BTH program: With great confidence With some confidence (please explain below) With confidence I do not recommend this student (please explain below) Keeping in mind that BTH classes are taught by high school and college students (under the supervision of mentor teachers and program staff), do you have any concerns about this student s ability to behave appropriately and maturely? Do you have any concerns about this student s ability to complete the six-year commitment? If you would like to be included on the BTH mailing list, please write your contact information below (if you are filling out multiple recommendation forms, you need only write your contact information on one form): Address street city zip 13

14 Math Teacher Recommendation Student s Name School Teacher s Name Subject(s) Taught Students: Write your name, school, teacher s name and the exact MATH class he or she teaches you above. Then give this form to your MATH teacher. Ask him or her to return it to you in a sealed envelope by February 8th. Return it in an envelope along with your application to your school representative or mail it to the Breakthrough Houston office by February 17th, (BTH, 2401 Claremont Ln. Houston, Tx 77019) Please circle the response that best suits the student, in relation to the student s peers. Academic No basis for Below Average Above Outstanding Judgment Average Average Academic motivation N Attitude towards homework N Study habits/organization N Math skills N Problem-solving skills N Intellectual curiosity N Overall academic skills/aptitude N Personal Willingness to try new activities N Ability to be a group leader N Willingness to volunteer in class N Enthusiasm for class projects N Ability to work independently N Self-confidence N Reaction to criticism N Sense of humor N Concern for fellow students N General level of maturity N Creativity N Ability to work well with adults N Overall personal qualities N What special interests, talents, or abilities could this applicant contribute to BTH? Are there any social, academic, or behavioral challenges that this student faces? 14

15 Teacher Recommendation continued How could this student benefit from participating in BTH? Describe this student s attitude toward homework, studying, and academic achievement. How much effort does this student put into achieving his or her goals? Does this student work AT or ABOVE grade-level in your subject? BTH is a program for dedicated, hard-working, and motivated students who want to go to college. I recommend this student for the BTH program: With great confidence With some confidence (please explain below) With confidence I do not recommend this student (please explain below) Keeping in mind that BTH classes are taught by high school and college students (under the supervision of mentor teachers and program staff), do you have any concerns about this student s ability to behave appropriately and maturely? Do you have any concerns about this student s ability to complete the six-year commitment? If you would like to be included on the BTH mailing list, please write your contact information below (if you are filling out multiple recommendation forms, you need only write your contact information on one form): Address street city Zip 15

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17 PLACEMENT TESTING MANDATORY FOR ALL APPLICANTS. Saturday March 7, :00AM 11:30AM St. John s Middle School 2700 Buffalo Speedway STUDENTS and PARENTS ARRIVE PROMPTLY at 8:30AM 9:00 9:20 Registration and Check In 9:20 10:00 Student and Parent Meeting: 9:20 to 11:15 Math testing, English testing 11:15 Parents pick-up students If you DO NOT come to this Placement Testing, your application will be removed from our files. If you have an emergency, please call us at or kheinzerling@sjs.org KEEP THIS PAGE 17

18 PARENT INFORMATION PAGE Your child has been selected to apply to Breakthrough Houston, a six-year, two-part, tuition-free academic enrichment program. This program seeks highly motivated students to participate in its three six-week summer sessions (one after 6 th grade and one after 7 th grade and one after 8 th grade), its comprehensive school-year program (during the 7 th and 8 th grade years), and its High-School Program during the high-school years. Breakthrough Houston is committed to a diverse student body representing the variety of ethnic backgrounds in the Houston area. Family involvement is an essential part of Breakthrough Houston. If your child is accepted to the program, you will be expected to attend a variety of family events during the summer and school year, including orientation, parent meetings, and Celebration evening. You will also be expected to plan family events, such as vacations, around these events. Attendance during the program is mandatory. APPLICATION DEADLINE DATE: February 15, 2008 If your child attends a BTH target school, have him or her turn in ALL parts of the application to the school Breakthrough Houston coordinator. If your child does not attend a BTH target school, mail all parts of the application to the address below. MAKE SURE YOU ALSO ENCLOSE A COPY OF YOUR CHILD S STANDARDIZED TEST SCORES (NOT TAKS), and LATEST REPORT CARD AS WELL AS A COPY OF YOUR FREE AND REDUCED LUNCH ACCEPTANCE AND INCOME TAX RETURN. For more information, contact Breakthrough Houston 2401 Claremont Lane Houston, TX Breakthrough Houston Summer Program Dates The Summer Program 2015 location is St. John s School. Parent Orientation & Student placement testing (MANDATORY for ALL applicants): Saturday, March 7, 2015 See the informational flier within the BTH application for more information. If you cannot attend the mandatory placement testing, you are responsible for scheduling a make-up within one week of the testing date in order for your application to be considered. Individual interviews will be held around spring break (mid-march) and you will be ed with a time for the interview. New Student Orientation (new students only) Saturday, May 9, AM Meet the Teachers Student and Parent Orientation: for all grades - Saturday, June 13, 2015 Summer Session: Monday, June 15 to Friday, July 24 *Classes held Monday-Thursday (8:00 a.m. 4:00 p.m.) and Friday (8:00 a.m. 1:30 p.m.) Celebration: Friday, July 24, 2015 Ms. Kathy Heinzerling Phone: (713) kheinzerling@sjs.org (Keep This Page) 18