Document 6524184

Available in Spanish
Visit our website:
www.highjumpchicago.org
or call 312.582.7700
MISSION STATEMENT: High Jump equalizes access to education for middle school students who have exhibited exceptional
academic ambition and potential, but are of limited economic means. We provide academic enrichment, guidance, and support to
students of diverse backgrounds, with the goal of sending our participants to superior college preparatory schools, ensuring their
success while they are there, and enhancing their ability to gain admission to highly regarded four-year colleges and universities.
2013-2014 APPLICATION COVER SHEET
Students entering the 7th grade in Fall 2014
General Requirements:
•
Student applicants must currently be in the sixth grade.
•
Students must have achieved a B or higher average in core subjects and have scored at or above the 70th percentile on
fifth grade Math and Reading standardized test. High Jump students typically earn more As than Bs.
•
Submit a completed application (See check list) by February 14, 2014. Applications may be mailed or dropped off
at High Jump Offices (59 W. North Blvd.). Mailed applications should be postmarked by February 14, 2014.
FAXED APPLICATIONS WILL NOT BE ACCEPTED.
Meet financial eligibility requirement, which is determined on a case-by-case basis and after all qualified applications
have been reviewed. The parent(s) or guardian(s) with whom the student resides, who claim the student as a
dependent on their income taxes and/or who have custody of the student are required to submit proof of
income documentation.
•
Note: Financial information is reviewed by authorized High Jump staff only, and is not shared, distributed or released
to outside parties. Review of financial information is strictly to determine a student’s need and eligibility for High
Jump’s academic enrichment program.
High Jump serves students from low-income backgrounds that have limited access to academic
enrichment programs in their communities/schools. High Jump equalizes access to education by serving
as a resource and support base for families whose position in life limits their access to top college
preparatory high schools. High Jump gives stronger consideration to students who will be the first in their
families to attend college.
Students enrolled in High Jump:
•
Are active participants in all of High Jump’s mandatory events, including: Orientation (prior to each session), three-day
and two-night retreat, Expo Day, High School Fair, high school visits, high school exam prep courses, class trips, and
Moving Up Ceremony.
•
Commit to attending and successfully completing a two year program which includes two six-week summer intensive
sessions of classes and Saturday classes held two/three times per month during the school year. The course of study
includes algebra, biology, physics, humanities and writing workshop, and grades are determined by homework, projects,
class participation and exams. Classes are held at the Latin School of Chicago, the Francis W. Parker School and the
University of Chicago Laboratory School.
•
Agree to apply to two different types of high schools – one public and one private (independent, parochial, or boarding) –
submitting applications to at least of three different high schools. Sit for required high school entrance exams such as the
ISEE, SSAT, Selective Enrollment Public, or Catholic School Entrance Exam.
HIGH JUMP ⎢ 59 W. NORTH BOULEVARD ⎢ CHICAGO, IL 60610 ⎢ P: 312.582.7700 ⎢ F: 312.582.7701
ask@highjumpchicago.org ⎢ www.highjumpchicago.org
Frequently Asked Questions
What is High Jump?
High Jump is tuition-free, year-round academic program that prepares Chicago middle school students
for top ranked college preparatory high schools, college, and beyond. Students engage in rigorous course
work, develop positive networks, and attend social and cultural events that broaden their horizons and
foster personal development. Participating students have high academic potential but face limited
opportunities and resources. High Jump is a 501c(3) nonprofit organization.
What are High Jump students like?
High Jump students are academically motivated and enthusiastic. They love having fun and value learning.
They live in neighborhoods throughout Chicago and are of varied cultural backgrounds. High Jump
students rank at the top of their class in their elementary schools. High Jump students are expected to
maintain grades of B and above throughout their time in High Jump and at school.
Who is eligible for High Jump?
Sixth grade students who excel academically are eligible to apply. Students who get As and Bs, enjoy
learning new things, and being challenged. They have a strong desire to attend a top college preparatory
high school and college after high school. High Jump admits students as 6th graders, and they begin the
program the summer before 7th grade. High Jump does not accept applications from 7th and 8th grade
students.
Who are the High Jump teachers?
High Jump teachers are professional educators who teach in a variety of public and private schools and
colleges throughout Chicago. Teachers are selected for their content area and instructional skill, and their
ability to challenge and motivate high performing students while maintaining strong teacher-student
relationships. They take a hands-on, interactive, exploratory, and project based approach to teaching;
nurture positive academic mindsets by encouraging student to work hard and take risks, and build
leadership characteristics such as self-advocacy and good decision-making.
What do students do at High Jump?
Students attend classes that are interactive and project-based, have hands-on activities, and incorporate
technology. Students solve complex math problems in algebra, dissect a cow’s heart in biology, build
bridges in physics, explore the humanities, read books, and write essays. They go on an over night
camping trip, participate in a talent show and Academic Expo, go on cultural excursions, and attend High
Jump’s high school fair and graduate at the Moving Up Ceremony.
Does the family have to pay anything?
High Jump is tuition-free. There is NO COST to you or your family. Breakfast and lunch is provided for
free during the summer and on Saturdays. However, each summer, High Jump asks each family to make
a family contribution. The family contribution is not required for students to participate in the program.
What is the commitment?
This is a two-year program. Your personal and family commitments should be scheduled around High
Jump during the times classes are in session. Students attend High Jump classes and other program
activities for six weeks in the summer, Monday – Friday, mid-June through July. During the school year,
students attend the Saturday program two or three times per month, mid-September through April.
Students are expected to attend and come prepared for each class, complete all assignments, and actively
participate in class discussions and group projects.
Where is High Hump?
High Jump has three Chicago locations: the Latin School of Chicago located 59 W. North Blvd, the Francis
W. Parker School located 330 W. Webster and the University of Chicago Laboratory School located 5835
S. Kimbark.
Is transportation provided?
High Jump provides free bus transportation, during the summer only, to students who do not have a
vehicle or cannot access public transportation. You and your family are responsible for providing
transportation to the Saturday session program. High Jump carpools are worked out, between parents, for
students who live in neighboring communities.
Who can qualify for High Jump?
Sixth grade students who demonstrate strong academic potential, value learning, and have dreams of
excelling academically. Determined learners who would like to develop critical thinking and problem
solving skills in writing, algebra, social studies, science, theatre and art.
What is the application process?
Submit a complete application along with school transcripts (or copy of 6th grade report card with at least
two quarters of graders, copy of final 5th grade report card), 5th grade standardized test scores with
percentile and stainine scores, student essays, three letters of recommendation, parent questionnaire, and
parent/guardian proof of income. See the application checklist for complete list of application components.
Once the application is reviewed, High Jump will interview a select number of students and their parents.
Candidates are notified of acceptance by May.
When is the application deadline?
The application deadline will be February 14, 2014. High Jump will accept applications starting January
7, 2014. Interviews occur March through April.
Do students go on field trips?
Throughout the year, classroom study is complemented by field trips to local cultural and educational
institutions such as The Art Institute, Chicago History Museum, Chicago Shakespeare Theatre and The
Steppenwolf Theatre. The summer sessions begins with a three-day outdoor education trip to Lorado Taft
at the Northern Illinois University Campus in Oregon, Illinois. Students are able to explore nature,
participate in trust building exercises and build leadership skills.
Top five reasons to attend High Jump?
1. Meet new friends. Come be a part of a super cool group of smart kids who love to learn and be
challenged.
2. Prepare for top college-preparatory high schools. Take advance-level classes to strengthen your
reading, writing, math and critical thinking skills.
3. Be a leader now. Learn to manage your time, get organized, make good decisions, take risks, be
a self-advocate, and be confident.
4. Explore new things. Go camping and explore the great outdoors. See a musical production or
science in 3D. Create a podcast, write a monologue or draw a self-portrait.
5. Expand your knowledge about high schools. Learn about a variety of public and private college
preparatory high schools in Chicago and across the country.
Mail or drop off applications to the High Jump Offices, 59 W. North Blvd.
Mailed applications should be postmarked by February 14, 2014.
FAXED APPLICATIONS WILL NOT BE ACCEPTED.
APPLICATION CHECK LIST
It is your responsibility to submit a completed application to High Jump by the required date, February 14,
2014. Applications may be mailed or dropped off at High Jump Offices (59 W. North Blvd.). Mailed
applications should be postmarked by February 14, 2014. FAXED APPLICATIONS WILL NOT BE
ACCEPTED. Late or incomplete applications will not be considered. They will automatically be disqualified.
Use black or blue ink to complete application. Do not use pencil.
 Application Forms
 5th AND 6th grade report cards
 Parent Questionnaire
 Standardized Tests: Current ISAT, Terra Nova,
and/or other standardized test scores
 Student Essay – handwritten and printed neatly by
student
 Completed Financial Eligibility Forms and copies of all
pages and Schedules of your 2011 and 2012 filed
1040 Federal Income Tax Forms; copies of all 2011,
2012 and 2013 W-2s, and/or 1099/1099R Forms. *NOTE:
2013 filed 1040 Federal Income Tax Forms may be
requested on a case-by-case basis
 Applicable items listed in the below Proof of Income
Section. A paycheck stub or State 1040 is NOT accepted as
proof of income.
 Transcript Release Statement Form – complete the top
portion and submit to applicant’s school office.
Transcripts must include 4th-6th grades.
 English Teacher Recommendation (signature across
sealed envelope)*
 Math Teacher Recommendation (signature across sealed
envelope)*
 Counselor/Principal Recommendation (signature across
sealed envelope)*
*Make sure the student name is on each recommendation
form. One recommender per form. A teacher may
complete both a Math and English recommendation only if
he/she teaches both subjects and can detail a student’s
performance in both subject areas.
PROOF OF INCOME DOCUMENTS
• Signed, official copies of 2011 and 2012 1040 Federal Income Tax Forms (include all pages/schedules submitted to
IRS)
• 2011, 2012 and 2013 W-2s and/or 2011, 2012 and 2013 1099/1099R Forms
If taxes were not filed, you must provide a notarized letter detailing the reason,
and a copy of one of the documents below, as applicable, as proof of income:
• Public Aid proof of public assistance from the Illinois Department of Health and Family Services
• Statement of Social Security Benefits 2012 and 2013
• Statement of foster care from Social Services
• Unemployment notice/statement of unemployment
• Statement of child support payments
• A copy of a valid Medicaid I.D. card (indicating candidate’s coverage)
• A current Link/Food Stamp voucher
• Proof of SSI (Supplementary Security Income) (indicating candidate’s coverage)
• Proof of Special Population Group (i.e. Social Security)
Carefully read and sign the following:
I/We, understand that if my application does not arrive by the deadline, or is not complete, it will not be reviewed and I will not be notified.
I/We, the undersigned, certify that all the information presented for the purpose of determining financial need is true to the best of our
knowledge, and that perjury or lack of required submission material will disqualify an application to High Jump.
High Jump reserves the right to dismiss any student(s) accepted under falsification of financial need or other pertinent application information.
Parent/Guardian 1: _______________________________________________________
Signature
_____/_____/______
Date
Parent/Guardian 2: _______________________________________________________
Signature
_____/_____/______
Date
HIGH JUMP ⎢ 59 W. NORTH BOULEVARD ⎢ CHICAGO, IL 60610 ⎢ P: 312.582.7700 ⎢ F: 312.582.7701
ask@highjumpchicago.org ⎢ www.highjumpchicago.org
HIGH JUMP APPLICATION FOR ADMISSION 2013-2014
APPLICANT GENERAL INFORMATION
Student Full Name: ______________________________________________________________________________
(First)
(Middle)
(Last)
Street Address: ______________________________________________________________ (Apt. #) ___________
City: ________________________________________
State: ___________
Zip code: ___________
Neighborhood: ________________________________________________________________________
Home phone: (
) ____________________________
Cell phone: (
) _____________________________
E-mail Address: _______________________________________________________________________
Date of Birth: _____ /______ /_____
Social Security Number: XXX-XX- __ __ __ __
Citizenship:
£ USA Citizen
£ USA Resident
Please select:
£ Male
£ Female
£ African American
£ Asian
£ Other: (specify) _______________________
£ Caucasian
£ Hispanic
£ Native American
£ Multi racial (please specify): _____________________________________________________
Student lives with (check all that apply):
£ Both Parents
£ Step-Father £ Grandparent(s)
£ Mother
£ Father
£ Step-Mother
£ Aunt
£ Uncle
£ Guardian(s)
Do you live in a Traditional Public Housing unit or a Housing Choice Voucher unit (Section 8)?
If so, please check which type: ❒ Traditional Public Housing unit
❒ Yes
❒ No
❒ Housing Choice Voucher unit (Section 8)
What language is spoken at home? _________________________________________________________________
How did you hear about High Jump? £ High Jump Student
£ Teacher/Counselor
£ Church
£ Other (specify): _____________________
£ High Jump presentation at my school
£ Internet
List the names of any relatives and/or friends who have attended or are currently enrolled in High Jump.
__________________________________________________________________________________________________________
Name
Relationship
Cohort
__________________________________________________________________________________________________________
Name
Relationship
Cohort
What high school do you want to attend and why? Name your top three choices.
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APPLICANT EDUCATION INFORMATION
Applicant current school: ________________________________________________________ Grade level: _______
School address: ________________________________________________________________________________
City: ________________________________________
State: ___________
Zip code: ___________
Neighborhood where school is located: ______________________________________________________
Type of school: £ CPS Public
£ Charter
£ Suburban Public
£ Parochial
£ Private
List any cultural, enrichment or academic programs and summer camps/programs attended or currently attending:
Program name: __________________________________ Start date: __ /__ /__ End date: __ /__ / __
Program name: __________________________________ Start date: __ /__ /__ End date: __ /__ / __
HIGH JUMP 2013-2014 PARENT/GUARDIAN INFORMATION
Female Parent or Guardian List parent/guardian/adult residing with applicant.
Check one:
£ Mother
£ Stepmother
£ Grandmother
£ Female Guardian
£ Separated
£ Divorced
£ Other (specify): ____________________
Marital Status:
£ Married
£ Single
£ Widowed
£ Other: _____________
Full Name: _____________________________________________________________________________________
(First)
(Middle)
(Last)
Address: ______________________________________________________________________________________
(Street Address)
(Apt. #)
City: ________________________________________
State: ___________
Zip code: ___________
Neighborhood: __________________________________________________________________________________
Daytime phone: (
Cell phone: (
) _____________________________ Evening phone: (
) ___________________________
) ____________________ E-mail Address: _____________________________________________
Date of Birth: _____ /______ /_____
Citizenship:
£ USA Citizen
£ USA Resident £ Other: (specify) _______________________
Female Parent or Guardian Education:
High School attended: _____________________________________________________________
£ Graduated
£ Did not graduate
£ GED
College/Trade School attended: _____________________________________________________
£ Two-year/Associate Degree
£ Four-year/Bachelor Degree
£ Master Degree
£ PhD
£ Some college
£ Trade certification/license (specify): _____________________
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Male Parent or Guardian List parent/guardian/adult residing with applicant.
Check one:
£ Father
£ Stepfather
£ Grandfather
£ Male Guardian
£ Separated
£ Divorced
£ Other (specify): ____________________
Marital Status:
£ Married
£ Single
£ Widowed
£ Other: _____________
Full Name: _____________________________________________________________________________________
(First)
(Middle)
(Last)
Address: ______________________________________________________________________________________
(Street Address)
(Apt. #)
City: ________________________________________
State: ___________
Zip code: ___________
Neighborhood: __________________________________________________________________________________
Daytime phone: (
Cell phone: (
) _____________________________ Evening phone: (
) ___________________________
) ____________________ E-mail Address: _____________________________________________
Date of Birth: _____ /______ /_____
Citizenship:
£ USA Citizen
£ USA Resident £ Other: (specify) _______________________
Male Parent or Guardian Education:
High School attended: _____________________________________________________________
£ Graduated
£ Did not graduate
£ GED
College/Trade School attended: _____________________________________________________
£ Two-year/Associate Degree
£ Four-year/Bachelor Degree
£ Master Degree
£ PhD
£ Some college
£ Trade certification/license (specify): _____________________
NONCUSTODIAL PARENT/GUARDIAN (S) INFORMATION
IF THE APPLICANT’S PARENTS ARE DIVORCED, SEPARATED OR SINGLE (NEVER MARRIED), THIS
INFORMATION MUST BE PROVIDED FOR THE NON-CUSTODIAL, BIOLOGICAL PARENT (Parent not
residing with applicant).
Marital Status:
£ Married £ Single £ Separated £ Divorced £ Remarried £ Widowed £ Other: _____________
Full Name: _____________________________________________________________________________________
(First)
(Middle)
(Last)
Spouse Name: __________________________________________________________________________________
(Please list if other than biological student applicant’s parent)
Address: ______________________________________________________________________________________
(Street Address)
(Apt. #)
City: ________________________________________
State: ___________
Zip code: ___________
Neighborhood: _________________________________________________________________________
Daytime phone: _____________________________ Evening phone: _____________________________
Cell phone: (
) ____________________ E-mail Address: _________________________________________
Date of Birth: _____ /______ /_____
Citizenship:
£ USA Citizen
£ USA Resident
£ Other: (specify) _______________________
Non-custodial Parent Guardian Education & Occupation:
High School attended: _____________________________________________________________
£ Graduated
£ Did not graduate
£ GED
College/Trade School attended: _____________________________________________________
£ Two-year/Associate Degree
£ Four-year/Bachelor Degree
£ Master Degree
£ PhD
£ Some college
£ Trade certification/license (specify): _____________________
Occupation: ___________________________
Employer: ___________________________
How much does this person contribute towards your annual household income? $ ___________________
Will the Non-custodial Parent be involved in activities, programs, meetings and other events hosted and/or required
by High Jump?
£ Yes
£ No
If yes, to what extent? __________________________________________________________________________
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Read carefully:
Your signature below indicates that all the information provided on this application form is complete and
factually correct. Your signature also attests to the fact that you wish for your child to be considered for
participation in High Jump with no guarantee of final acceptance. It also authorizes High Jump to request
a copy of the applicant’s academic report with the most recent grades and standardized test scores.
Signature of parent or guardian: _________________________________________________________
Date signed (month/ date/ year): ______ / ______ / ______
HIGH JUMP STANDS BEHIND THE PRINCIPLE THAT THERE SHALL BE NO DISCRIMINATION AGAINST ANY PERSON IN ADMISSION,
EMPLOYMENT, OR OTHERWISE BECAUSE OF RACE, COLOR, RELIGION, NATIONAL ORGIN, DISABILITY, GENDER, SEXUAL
ORIENTATION OR AGE.
HIGH JUMP ⎢ 59 W. NORTH BOULEVARD ⎢ CHICAGO, IL 60610 ⎢ P: 312.582.7700 ⎢ F: 312.582.7701
ask@highjumpchicago.org ⎢ www.highjumpchicago.org
2013-2014 PARENT/GUARDIAN QUESTIONNAIRE
High Jump’s academic enrichment program involves a rigorous course curriculum with homework assignments,
projects, quizzes and exams. Students meet Monday through Friday for six weeks during the summer and on
Saturdays during the school year. High Jump expects students to manage assignments from their home school and
High Jump. We are committed to each student’s success and provide a variety of services such as one-on-one tutoring,
time management and organizational skill development.
High Jump is not an extracurricular activity and does not excuse students for activities such as debate
competitions, choir rehearsals, sport games/tournaments, music lessons, religion school, etc.
Question #1
What impact will participation in High jump have on your child?
__________________________________________________________________________________
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Question #2
What type of academic development, cultural enrichment, sporting, musical or other programs is your child involved
in? How often do they meet? If the applicant is accepted into High Jump, will he/she continue to participate in these
activities?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
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Question #3 (DO NOT LEAVE BLANK)
Often High Jump families meet the income guideline for the Illinois Free and Reduced Breakfast/Lunch Program.
Does your child receive a Free Breakfast/Lunch? £ Yes £ No
OR
Reduced Breakfast/Lunch? £ Yes
£ No
Question #4 (DO NOT LEAVE BLANK)
High Jump’s mission is to serve students from families with limited financial resources. How does this apply to you?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
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2013 – 2014 STUDENT ESSAY QUESTIONS
Student Name: ____________________________________________________________________
Please answer both questions with a 250-word essay per question. Please count the number of
words and write the total at the end of each essay question. Handwrite essays in black or blue ink.
Essay will be retuned to applicants who submit typed essays. DO NOT TYPE ESSAYS
Question #1
If you could have one superpower, what would it be and how would you use it?
Question #2
If you were given $500 to spend on someone other than yourself, who would you spend it on and why?
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STUDENT ESSAY QUESTIONS CONTINUED
Student Name: ____________________________________________________________________
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HIGH JUMP 2013-2014 FINANCIAL ELIGIBILTY FORMS (SECTIONS A-J)
A
Parent/Guardian 1 Income Data (Person financially responsible for student applicant)
£ Mother £ Father £ Stepmother £ Stepfather £ Grandmother £ Grandfather £ Guardian £ Other Adult
Last Name
First Name
MI
Employment Information (DO NOT LEAVE BLANK)
What is your current employment status? £ Full Time
£ Part Time
If unemployed, are you receiving unemployment benefits? £ Yes
£ Self-employed
£ No
£ Retired
£ Unemployed
Weekly amount $ __________________
How long unemployed? ____________ Name of last employer? __________________________________________
Occupation (type of work): ___________________________________________ Industry: ____________________
Current Employer: __________________________________________________ Numbers of Years Employed: ___
Company/Organization/Institution
Employer Street Address: _______________________________________________________________
City: _______________________ State: ___________ Zip: __________
Phone (
) __________________
Occupation (type of work): ___________________________________________ Industry: ____________________
Annual Salary $ ___________ Net monthly take home pay (after taxes and deductions) $ __________
Do you work a second Job? £ Full Time £ Part Time
£ No
Annual Salary $ ___________ Net monthly take home pay (after taxes and deductions) $ __________
If employed less than three years, list previous employer and salary history: _________________________________
______________________________________________________________________________________________
If Parent/Guardian 1 does not earn a salary or collect unemployment, indicate how living expenses are covered.
_____________________________________________________________________________________________
______________________________________________________________________________________________
B
Parent/Guardian 2 Income Data (Person financially responsible for student applicant)
£ Mother £ Father £ Stepmother £ Stepfather £ Grandmother £ Grandfather £ Guardian £ Other Adult
Last Name
First Name
MI
Employment Information (DO NOT LEAVE BLANK)
What is your current employment status? £ Full Time
£ Part Time
If unemployed, are you receiving unemployment benefits? £ Yes
£ Self-employed
£ No
£ Retired
£ Unemployed
Weekly amount $ __________________
How long unemployed? ____________ Name of last employer? __________________________________________
Occupation (type of work): ___________________________________________ Industry: ____________________
Current Employer: __________________________________________________ Numbers of Years Employed: ___
Company/Organization/Institution
Employer Street Address: _______________________________________________________________
City: _______________________ State: ___________ Zip: __________
Phone (
) __________________
Occupation (type of work): ___________________________________________ Industry: ____________________
Annual Salary $ ___________ Net monthly take home pay (after taxes and deductions) $ __________
Do you work a second Job? £ Full Time £ Part Time
£ No
Annual Salary $ ___________ Net monthly take home pay (after taxes and deductions) $ __________
If employed less than three years, list previous employer and salary history: _________________________________
______________________________________________________________________________________________
If Parent/Guardian 2 does not earn a salary or collect unemployment, indicate how living expenses are covered.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
C
Dependents List all dependents living in your household. For example: children, senior
parents etc. (DO NOT LEAVE BLANK)
Full Name
Age
If in school,
current grade
Tuition
Amount You
Pay
School Student will attend in the fall of
2014 (Do not abbreviate)
List others (nondependent) living in your household (not reported on your most recent tax return)
Name _______________________________________________________ Relationship: ______________________
Financial contribution to household: _______________ If none, explain ____________________________________
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Name _______________________________________________________ Relationship: ______________________
Financial contribution to household: _______________ If none, explain ____________________________________
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D
Divorced, Separated or Single Parents (Do Not Leave Blank if applicable)
1. Date of separation (Month/Year) ________
2. Date of Divorce (Month/Year) __________
3. Who claimed student as a tax dependent in
2011? ___________________ in 2012?
_______________ in 2013 ____________ ? 4. Do you receive or pay child support? £ Receive $ __________ per year
£ Pay $ __________ per year
£ Neither - If you are not receiving any
child support submit a notarized letter detailing
your efforts to collect, and the other parent’s
inability or reluctance to pay. Non-custodial parent ________________________________________________________________________
Last Name
First Name
MI
E
Personal Property (DO NOT LEAVE BLANK)
Do you rent or own your residence?
£ Rent
£ Own
If you rent your property, what is the monthly rental payment? $ ______________________
Amount paid by household $ _______________ per month
Amount paid by other source(s) $ _______________ per month
5.
Personal Property Continued (DO NOT LEAVE BLANK)
If you own your residence, what is your mortgage balance? $ __________ Monthly Payment $ ______________
Purchase amount $ _______________
Year purchased _________
Amount paid by household $ _______________ per month
Amount paid by other source(s) $ _______________ per month
Do you own income property?
What type?
£ Yes
£ No
£ Condo
£ Multi-unit*
£ House
If yes, what is the monthly mortgage $ __________ If yes, what is monthly rental income $ ______________
* Do you live in multi-unit income property?
Do you own a vehicle (s)?
£ Yes
£ Yes
£ No
£ No
If yes, indicate number of vehicles _________
Vehicle #1: Make, model and year ___________________________________________________
Year purchased: _____ Purchase Amount $ ________ Car Balance $ ________ Monthly Payment $ ________
Vehicle #2: Make, model and year ___________________________________________________
Year purchased: _____ Purchase Amount $ ________ Car Balance $ ________ Monthly Payment $ ________
F
Household Income Sources (DO NOT LEAVE BLANK)
Please list monthly net income* amounts for each item.
Parent/Guardian 1 *net monthly salary, Job #1
$ ______________
per month
Parent/Guardian 1 *net monthly salary, Job #2
$ ______________
per month
Parent/Guardian 2 *net monthly salary, Job #1
$ ______________
per month
Parent/Guardian 2 *net monthly salary, Job #2
$ ______________
per month
Other contributor(s) (stepparent) salary
Social Security benefits (SSI/SSD, etc.)
(Provide documentation for all recipients in household)
$ ______________
per month
$ ______________
per month
Cash Assistance (TANF)
$ ______________
per month
Link/Food Stamps
$ ______________
per month
**Child support
$ ______________
per month
**Alimony
$ ______________
per month
Veteran’s pension
$ ______________
per month
Worker’s compensation, disability, etc.
$ ______________
per month
Unemployment
Other sources of income
(include rental property)
$ ______________
per month
$ ______________
per month
$ ______________
per month
TOTAL MONTHLY HOUSEHOLD INCOME
*Amount of pay after taxes (take-home pay).
** If child support/alimony is not being received per court order, please provide a separate and notarized statement
detailing the circumstances, and whether or not support is being sought after.
√ Detail other sources of income: ______________________________________________________________
____________________________________________________________________________________________
Do your monthly expenses exceed your monthly income? £ Yes £ No
How do you cover the difference? ______________________________________________________________
____________________________________________________________________________________________
G
Assets & Investment As of 12/31/13 (DO NOT LEAVE BLANK)
Total amount in cash, checking and savings accounts
$ __________
Total value of money market funds, mutual funds, stocks, bonds, CDs or other securities
$ __________
Total value of IRA, Keogh, 401K, SEP or other retirement accounts
$ __________
Did you take a distribution in 2010, 2011 or 2012? £ Yes £ No
If yes, how much and why? _________________
_____________________________________________________________________________________________
H
Unusual Circumstances
Check all that apply to your situation within the last twelve (12) months:
a.
£ Loss of job
i.
£ Illness or injury
b.
£ Recent separation/divorce
j.
£ Death in the family
c.
£ Change in family living status
k.
£ Shared custody
d.
£ Change in work status
l.
£ High debt
e.
£ Bankruptcy
m. £ Child support
f.
£ Home foreclosure
n.
£ Medical/Dental expenses
g.
£ College expenses
o.
£ Tuition (Elementary or High School)
h.
£ Income reduction
p.
£ Other (Explain circumstances) _____________________________________________________________
________________________________________________________________________________________
I
Business Income 2012 and 2013 Totals (DO NOT LEAVE BLANK)
What type of business(s) do you own? _______________________________________________________________
What is your total estimated GROSS business taxable income?
Section C
$ ________
Section E
$ ________
Section F
$ ________
What is your total NET business taxable income/loss?
$ ________
$ ________
$ ________
If your business pays for your home rent or mortgage, what s the annual total?
$ _________________
If your business pays for your personal automobile, what is the annual total?
$ _____________________
If your business pays for any portion of other personal expenses,
list total amount and explain in SECTION J.
If you own rental property: What was the total amount of Rental Income received?
J
$ _____________________
$ _____________________
Explanation
Use this space to explain any answers that may need clarification or any special circumstances or reasons for
leaving any sections blank regarding guardians, non-custodial parents, or household or financial
circumstances.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
________________________________________________________________________________________
2013-2014 ENGLISH TEACHER RECOMMENDATION
Applicant Name:
________________________________________________________
To the applicant: Fill in your name above and give this form to your English teacher along with a stamped return envelope addressed to High
Jump, 59 W. North Blvd., Chicago, IL 60610-1492.
To the teacher: The student listed above has applied for admission to High Jump. High Jump is a tuition-free, two-year academic enrichment
program for talented seventh and eighth grade students with limited financial resources. High Jump students excel academically. They often
complete their work before classmates and request additional or more challenging work.
Students attend an intensive six-week session of summer classes as well as classes on Saturdays during the school year. They participate in
challenging courses such as algebra, biology, physics, humanities and language arts. The courses require homework, projects and exams.
Students who enjoy school and being challenged academically thrive in our program, as they are required to maintain two course loads during
the school year.
We would appreciate any information you can provide that will help us make an informed decision regarding this student’s application. Your
comments will be strongly considered in our evaluation.
Please place your completed recommendation in an envelope. Sign the envelope across the back flap and return it to the student or
mail to: High Jump, 59 W. North Boulevard, Chicago, IL 60610-1492
High Jump serves students from low-income backgrounds that have limited or no access to academic enrichment programs in their communities or
schools. High Jump equalizes access to education by serving as a resource and support base for families whose position in life limits their access to top
college preparatory high schools. High Jump helps prepare students for entry into challenging college preparatory high schools. High Jump gives
stronger consideration to students who will be the first in their families to attend college.
General Information:
Teacher name: __________________________________________________________________
Teacher’s e-mail address: _________________________________________________________________
School name: __________________________________________________________________________
Address: _________________________________________________ City: ________________________
State: ________
Zip: ________
Phone: ________________ Fax: ___________________
How long and in what capacity have you known this student? ___________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Course Description
What course is this student currently taking? _____________________ Grade Average: _______
Please give us a brief course description. ______________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
What text and/or related readings are used? ____________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Does this student possess any particular strengths or weaknesses? ____________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Student Evaluation: In comparison to other students of the same age you have known at
your school and over your career, how would you rate the applicant in the following areas?
Evaluation Criteria
Below
Average
Average
Very
Good
Outstanding
One of my
very best
No basis for
judgment
This student is able to analyze the
meaning of words and phrases in their
context.
This student is familiar with a variety of
literary genres and can identify their
features.
This student is able to incorporate new
words into his or her vocabulary.
This student is familiar with a variety of
writing styles, including research reports.
This student expresses him/herself well in
writing using standard conventions of the
English language.
This student takes criticism well and learns
from mistakes.
This student uses reading comprehension
strategies to improve understanding of a
text.
This student reads age appropriate
material with fluency and accuracy.
This student uses information from a text
to form, explain and support questions and
predictions.
This student shows a genuine interest in
and enthusiasm for acquiring new
knowledge.
This student can read critically to question
and analyze an author’s choices.
This student can respond as a reader to
written material from personal, creative
and critical points of view.
This student writes documents that clearly
address the purpose and audience of the
assignment.
How will this student contribute to the High Jump community? If you have any reservations, please detail them below as
well. ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ Thank you for your time and the information you have provided. If you wish to learn more about High Jump, please call
us at 312.582.7700 or email us at ask@highjumpchicago.org
Teacher Signature: ____________________________________________________________________ Date: ____________________ HIGH JUMP 2013-2014 APPLICATION 2013-2014 COUNSELOR/PRINCIPAL
RECOMMENDATION
Applicant Name:
_______________________________________________________
To the applicant: Fill in your name above and give this form to your counselor/principal along with a stamped return envelope addressed
to High Jump, 59 W. North Blvd., Chicago, IL 60610-1492.
To the Counselor/Principal: The student listed above has applied for admission to High Jump. High Jump is a tuition-free, two-year
academic enrichment program for talented seventh and eighth grade students with limited financial resources. High Jump students excel
academically. They often complete their work before classmates and request additional or more challenging work.
Students attend an intensive six-week session of summer classes as well as classes on Saturdays during the school year. They
participate in challenging courses such as algebra, biology, physics, humanities and language arts. The courses require homework,
projects and exams. Students who enjoy school and being challenged academically thrive in our program, as they are required to maintain
two course loads during the school year.
We would appreciate any information you can provide that will help us make an informed decision regarding this student’s application.
Your comments will be strongly considered in our evaluation.
Please place your completed recommendation in an envelope. Sign the envelope across the back flap and return it to the student
or mail to: High Jump, 59 W. North Boulevard, Chicago, IL 60610-1492
High Jump serves students from low-income backgrounds that have limited or no access to academic enrichment programs in their communities or
schools. High Jump equalizes access to education by serving as a resource and support base for families whose position in life limits their access
to top college preparatory high schools. High Jump helps prepare students for entry into challenging college preparatory high schools. High Jump
gives stronger consideration to students who will be the first in their families to attend college.
General Information:
Your name: ________________________________________________________________________
Title: _____________________________________________________________________________________
School name: ______________________________________________________________________
Address: ________________________________________________ City: _____________________
State: ________
Zip: ________
Phone: ___________________
Fax: ___________________
Email address:_________________________________________________________________
How long and in what capacity have you known this student? ____________________________________
________________________________________________________________________________
Does this student qualify for the Illinois Free and Reduced Breakfast and Lunch Program?
Please circle one: Free Breakfast/Lunch OR Reduced Breakfast/Lunch
Parental Involvement
Parents are an important part of our relationship with the student. Please share with us any thoughts you have
regarding this family and their commitment to their child's development.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Does this student have an IEP or any special academic, physical or behavioral circumstances? If yes, please
describe.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Student Evaluation
In comparison to other students of the same age you have known at your school and over your career,
how would you rate the applicant in the following areas?
Evaluation
Criteria
Below
Average
Average
Very
Good
Outstanding
One of my
very best
No basis for
judgment
Concern for others
Respect for authority
Maturity
Leadership
Integrity/Honesty
Reaction to criticism
Self-confidence
Independence &
Initiative
Creativity
Critical thinking
Study habits
Oral expression
Class participation
Writing ability
Ability to work in a
group
Seeks help when
needed
Overall academic
achievement
Overall personal
qualities
How will this student contribute to the High Jump community? If you have any reservations, please detail them below as
well.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Thank you for your time and the information you have provided. If you wish to learn more about High Jump,
please call us at 312.582.7700 or email us at ask@highjumpchicago.org
Teacher signature: _________________________________
HIGH JUMP 2013-2014 APPLICATION
Date: _______________
2013-2014 MATH TEACHER RECOMMENDATION
Applicant Name:
__________________________________________________________ To the applicant: Fill in your name above and give this form to your math teacher along with a stamped return envelope addressed to High
Jump, 59 W. North Blvd., Chicago, IL 60610-1492.
To the teacher: The student listed above has applied for admission to High Jump. High Jump is a tuition-free, two-year academic enrichment
program for talented seventh and eighth grade students with limited financial resources. High Jump students excel academically. They often
complete their work before classmates and request additional or more challenging work.
Students attend an intensive six-week session of summer classes as well as classes on Saturdays during the school year. They participate in
challenging courses such as algebra, biology, physics, humanities and language arts. The courses require homework, projects and exams.
Students who enjoy school and being challenged academically thrive in our program, as they are required to maintain two course loads during
the school year.
We would appreciate any information you can provide that will help us make an informed decision regarding this student’s application. Your
comments will be strongly considered in our evaluation.
Please place your completed recommendation in an envelope. Sign the envelope across the back flap and return it to the student or
mail to: High Jump, 59 W. North Boulevard, Chicago, IL 60610-1492
High Jump serves students from low-income backgrounds that have limited or no access to academic enrichment programs in their communities or
schools. High Jump equalizes access to education by serving as a resource and support base for families whose position in life limits their access to top
college preparatory high schools. High Jump helps prepare students for entry into challenging college preparatory high schools. High Jump gives
stronger consideration to students who will be the first in their families to attend college.
General Information:
Teacher name: __________________________________________________________________
Teacher’s e-mail address: _________________________________________________________________
School name: __________________________________________________________________________
Address: _________________________________________________ City: ________________________
State: ________
Zip: ________
Phone: _________________ Fax: ______________________
How long and in what capacity have you known this student? ___________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Course Description
What course is this student currently taking? _____________________ Grade Average: _______
Please give us a brief course description. ______________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Is this course sectioned according to ability?
£Yes
£No If this course is sectioned, please briefly explain how it’s
sectioned and applicants placement. __________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Does this student possess any particular strengths or weaknesses? ____________________________________
____________________________________________________________________________________
____________________________________________________________________________________
.
Student Evaluation:
Please comment on the student’s work in mathematics. Provide both a numerical and a letter
response for each question below:
Numerical Scale:
How would the student fare when answering the question?
1 - Would show little or no comprehension.
2 - Would show comprehension, but will frequently make errors.
3 - Would show significant comprehension, making errors infrequently.
4 - Would show complete comprehension, rarely or never making errors.
Letter Scale:
Has the material relevant to the questions below been covered in the student’s curriculum?
N – Has not been covered yet for this student
C – Has already been covered for this student
W – Has not been covered yet, but will be by the end of the school year
Questions
Numerical
Letter
1–4
N,C,W
1) Evaluate: 3/8 + 1/24 + 13/48 – 1/12 -1/16
2) Given a =5, b =3, c = 4. Evaluate the following: a2 – (b + c)
3) Tossing a regular coin 3 times, what is the probability of getting heads
every time?
4) Please attempt to simply the expression below, identify what is wrong with it.
(4 + 16) ÷ (12 – 2 x 6)
5) T-Shirts & More Print Shop will print any image on a Frisbee for a cost of $2
per Frisbee and a one-time charge of $12 to set up the Frisbee design.
Which algebraic equation shows the cost, C, of printing f Frisbees?
C = 2f
C = 12f + 2
C = 2C + 12
C = 2f + 12
What else would you like us to know about this student’s mathematical ability?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
How will this student contribute to the High Jump community? If you have any reservations, please detail them below as
well.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Thank you for your time and the information you have provided. If you wish to learn more about High Jump, please call us at
312.582.7700 or email us at ask@highjumpchicago.org
Teacher Signature: _____________________________________ Date: ________
HIGH JUMP 2013-2014 APPLICATION
2013-2014 TRANSCRIPT RELEASE STATEMENT
To the parent:
Please sign the release statement below and give this form to your child’s
school principal/counselor. To complete your child’s application, it is necessary
that we receive a copy of his or her transcripts attached to this form.
Applicant name: ________________________________________________________________________________
Current school: _________________________________________________________________________________
School address: ____________________________________ City: ______________ State: ______ Zip: _________
Principal/Counselor name: ________________________________________________________________________
Applicant address: _______________________________________________________ Apt. # _________________
City: __________________________ State: _____________________ Zip: _______________________
Home phone: ______________________________________ Daytime phone: _______________________________
--------------------------------------------------------------------------------------------I ______________________ (parent/guardian name) give ___________________________ (school name)
permission to release transcripts, report cards and standardized test scores to High Jump to be used for the
consideration of _________________ (student’s name) application for admission into its academic enrichment
program.
Guardian’s signature: ________________________________________________
Date: ___________________
--------------------------------------------------------------------------------------------To the principal/counselor: The student named above is an applicant for admission to High Jump.
Please submit the following records by the application deadline, February 14, 2014.
•
Fifth grade final grade report
•
Sixth grade, first and second quarter grade report
•
Transcripts (grades four through six)
•
Standardized test scores with percentile rank, and stanine scores
Please return this form along with the records to:
High Jump
59 W. North Boulevard
Chicago, IL 60610-1492
High Jump equalizes access to education for middle school students who have exhibited exceptional academic ambition and potential,
but are of limited economic means. We provide academic enrichment, guidance, and support to students of diverse backgrounds,
with the goals of sending our participants to superior college preparatory schools, ensuring their success while they are there, and
enhancing their ability to gain admission to highly regarded four-year colleges and universities.
HIGH JUMP ⎢ 59 W. NORTH BOULEVARD ⎢ CHICAGO, IL 60610 ⎢ P: 312.582.7700 ⎢ F: 312.582.7701
ask@highjumpchicago.org ⎢ www.highjumpchicago.org