Application for Admission

 2016-2017 Application for Admission

  Application and supplemental documents must be completed and returned to PCEC by April 15, 2016. 

 

  Student’s Personal Data:

  Student Name: __________________________________________________________________________

  NCWISE#: ___________________                            Date of Birth: ____/______/_________

  Social Security Number (Required by College): ______-______-________

  Street Address: _________________________________________________________________________

  City: ______________________          Zip: __________

  Mailing Address (if different): ____________________________________________________________

  Home Phone: ( ____ ) ________________ Cell Phone: ( ____ ) _________________

 

  How did you hear about Polk County Early College High School?              _______________________________________________________________________________________________________________________________________________________________________________

 

  Student resides with:

  ___ Mother & Father ___ Mother Only ___ Mother & Stepfather

  ___ Father Only ___ Father & Stepmother ___ Guardian

  ___ Other (please specify) _______________________________________

 

  Name(s) of the adults indicated above:

  Mother/Female Guardian Name: _______________________________________

  Father/Male Guardian Name: __________________________________________

 


  Education Data:

 Current School: ______________________________________________________________________________

 

  What career do you plan to pursue? ______________________________________________________________

 

  What problems (personal, social, academic, or disciplinary) have you had in your school experiences? Be specific.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

  Do you consider yourself a mature candidate for the Polk County Early College High School Program?  Why/why not? Defend your answer.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

  WRITING SAMPLE

  In your own words, please answer the question, “Why is Polk County Early College High School the right place for you?” (Attach a separate sheet for this     writing sample. There is a 100-word minimum. It can be typed or legibly written.)

 

  THREE REFERENCES REQUIRED. One reference should be from your school counselor, one from a teacher at your current school, and one should     be from someone who can speak to your character traits within the community (not a relative).

 

  Reference #1: Counselor Name: ________________________________________________________________

  Address: ____________________________________________ Phone: ________________________________

 

  Reference #2: Teacher Name: __________________________________________________________________

  Address: ____________________________________________ Phone:_________________________________

 

  Reference #3: Community Representative Name: __________________________________________________

  Address: ____________________________________________ Phone:________________________________

 

Comments