2016 application forms
2016 APPLICATION FORMS
Checklist for Applying to Cushing Summer Session Programs The Cushing Summer Session Office looks forward to receiving your application for one of our programs. Applications are reviewed on a rolling basis until all places are filled. To ensure a space in this summer’s program, your application should be completed as soon as possible. THE FOLLOWING ITEMS ARE REQUIRED TO COMPLETE YOUR APPLICATION ALL STUDENTS NEED TO COMPLETE: q
1. Student Application: Please complete this form yourself, and check off the academic program for which you are applying.
q
2. Parent Section: This section, on the back of the Student Application, is for your parents so that we can get all the information we need to be in touch with them about your summer.
q
3. Personal Essay: Please answer one of the three questions to help us get to know you better.
q 4. Find the program you are applying to in the list below, and make sure you have completed and checked off the necessary forms to send back. q
5. $60 processing fee: Send the processing fee to Cushing Academy Summer Session, PO Box 8000, Ashburnham, MA 01430. Your application will not be considered until the processing fee is received at Cushing.
q
6. Please include a recent photograph.
COLLEGE PREP AND CRITICAL SKILLS APPLICANTS q
Humanities Teacher Recommendation: Please give this recommendation form to your current English teacher.
q
Mathematics Teacher Recommendation: Please give this recommendation form to your current mathematics teacher.
q
Transcript Release: Fill out this form, have your parents sign it, and then give it to the registrar at your current school.
ENGLISH AS A SECOND LANGUAGE* q
Humanities Teacher Recommendation: Please give this recommendation form to your current English or E.S.L. teacher.
q
Transcript Release: Fill out this form, have your parents sign it, and then give it to the registrar at your current school. *Students applying to the Integrated Skills for Advanced Students Preparing for TOEFL iBT must provide proof of advanced language proficiency.
PREP FOR SUCCESS APPLICANTS q
Humanities Teacher Recommendation: Please give this recommendation form to your current English or E.S.L. teacher. or
q
Mathematics Teacher Recommendation: If you are applying for Prep for Success Mathematics or Robotics, give this recommendation form to your current mathematics teacher.
q
Transcript Release: Fill out this form, have your parents sign it, and then give it to the registrar at your current school.
STUDIO ART APPLICANTS q
Humanities Teacher Recommendation: Please give this recommendation form to your current art teacher.
q
Transcript Release: Fill out this form, have your parents sign it, and then give it to the registrar at your current school.
1
APPLICATION FOR ADMISSION CUSHING SUMMER SESSION
Student Application
CUSHING ACADEMY 39 School Street Ashburnham, MA 01430-8000 USA
tel: 978.827.7700 fax: 978.827.7087 e-mail: [email protected]
TO THE APPLICANT This application should be filled out promptly and returned via fax, mail, or e-mail to the Cushing Academy Summer Session Office with the required, non-refundable application fee of US $60. If you choose to fax the application, please include the Credit Card Payment Form (on page 10 of application) to secure payment of the application fee. Applications are acted upon by the Admission Committee when they are complete. Student Name (as it appears on passport)_______________________________________________________________________
last (family) name
first name
middle name
Address___________________________________________________________________________________________________
number an d street
city
state or country
zip code
Home phone ___________________________________________ Student Cell________________________________________ Student e-mail_____________________________________________________________________________________________ Birthdate_________________________ q Male q Female
Student's age_______________________________________
month/day/year
Citizenship_____________________________________________ Country of birth_____________________________________ Name of present school ___________________________________ Current grade_______________________________________ From whom or how did you learn about Cushing Academy?_________________________________________________________
Please select the desired academic program (check only one triangle below): r ACADEMIC PROGRAMS FOR STUDENTS AGES 12–13:
r ACADEMIC PROGRAMS FOR STUDENTS AGES 14–18: (check only one circle below)
PREP FOR SUCCESS CORE COURSES
q LITERATURE AND WRITING q MATHEMATICS q ROBOTICS q ENGLISH AS A SECOND LANGUAGE
COLLEGE PREP (choose one course from the section below)
(choose one course from the section below)
CRITICAL SKILLS ACROSS THE CURRICULUM in English, Mathematics and Study Techniques
q RESPONDING TO LITERATURE THROUGH
r PROGRAM FOR STUDENTS AGES 13–18:
q STUDIO ART AND
PORTFOLIO PREPARATION
CRITICAL AND CREATIVE WRITING
q UNITED STATES HISTORY q ALGEBRA I q GEOMETRY q ALGEBRA II q STATISTICS q PRECALCULUS q BIOLOGY q CHEMISTRY q PHYSICS q COLLEGE ADVISING WORKSHOP
ENGLISH AS A SECOND LANGUAGE (choose one course from the section below)
q STANDARD ESL (LISTENING
SPEAKING/READING/WRITING)
q INTEGRATED SKILLS FOR
ADVANCED STUDENTS
PREPARING FOR TOEFL IBT
2
PARENT INFORMATION Father’s name_____________________________________________
Mother’s name____________________________________________
Home address_____________________________________________
Home address_____________________________________________
________________________________________________________
________________________________________________________
Home phone______________________________________________
Home phone______________________________________________
Cell phone _______________________________________________
Cell phone _______________________________________________
Business phone___________________________________________
Business phone___________________________________________
Business fax______________________________________________
Business fax______________________________________________
E-mail address____________________________________________
E-mail address____________________________________________
Occupation_______________________________________________
Occupation_______________________________________________
If parents are separated or divorced, who is the custodial parent? ______________________________________________________________ To whom should reports be sent?_________________________________________________________________________________________ To whom should bills be sent?____________________________________________________________________________________________ PERSON TO BE CONTACTED IN CASE OF EMERGENCY IF PARENT/GUARDIAN CANNOT BE REACHED (IF POSSIBLE, INTERNATIONAL STUDENTS SHOULD LIST A CONTACT IN THE UNITED STATES): Name________________________________________________________________________________________________________________
last (family) name
first name
middle name
Address______________________________________________________________________________________________________________
number and street
city
state or country
zip code
Primary phone ______________________________________________ Cell phone________________________________________________ Work phone _________________________________________________ E-mail___________________________________________________
AUTHORIZATION I authorize this application and assume responsibility for tuition and other expenses. I understand that my child will be subject to all school regulations. In the event of an emergency, I authorize medical treatment as deemed necessary by competent health personnel. I also understand that in the event of early withdrawal or dismissal of my child from the school, the remaining tuition is forfeited Information regarding background checks, health care and discipline policies, as well as procedures for filing grievances, may be requested.
Parent signature ________________________________________________________________________ Date__________________________
PAYMENT Please make certain the application is complete and the processing fee is included by checking one of the following: q
Enclosed please find my check or money order for payment of the $60 processing fee. Make checks payable to: Cushing Academy Summer Session.
q
Enclosed please find my Credit Card Payment Form (on page 10 of application).
Please note: Your application will not be considered until the processing fee is received by Cushing. Decisions are made without regard to race, religion, sex, creed, national origin, or any other protected category under applicable law. Cushing Academy has no restrictions on its admission policy regarding race, religion, sex, creed, national origin, or any other protected category under applicable law. Candidates are judged solely on the basis of references, personal interviews, and school program of studies. We seek students who are seriously interested in preparing for college and who indicate they will be mature members of the Academy student body.
3
APPLICATION FOR ADMISSION CUSHING SUMMER SESSION
Personal Essay
CUSHING ACADEMY 39 School Street Ashburnham, MA 01430-8000 USA
tel: 978.827.7700 fax: 978.827.7087 e-mail: [email protected]
At Cushing we try to learn as much about each individual student as we can. Please take a few minutes to help us get to know you better by answering one of the questions below. PLEASE WRITE IN YOUR OWN HANDWRITING BELOW OR PRINT OUT YOUR RESPONSE ON A SEPARATE SHEET OF PAPER AND ATTACH IT TO THIS SHEET.
CHOOSE ONE: What do you think would be valuable for us to know about you and why? Why are you applying to Summer Session? What do you hope to achieve? Tell us about a time that you were challenged by something. (What was it? What did you do? What was the outcome?) _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ (continued on back)
4
(Personal Essay continued) _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________
Student’s signature__________________________________________________________ Date_______________________________________ Name (please print)_____________________________________________________________________________________________________
Decisions are made without regard to race, religion, sex, creed, national origin, or any other protected category under applicable law. Cushing Academy has no restrictions on its admission policy regarding race, religion, sex, creed, national origin, or any other protected category under applicable law. Candidates are judged solely on the basis of references, personal interviews, and school program of studies. We seek students who are seriously interested in preparing for college and who indicate they will be mature members of the Academy student body.
5
APPLICATION FOR ADMISSION CUSHING SUMMER SESSION
Humanities Teacher Recommendation
CUSHING ACADEMY 39 School Street Ashburnham, MA 01430-8000 USA
tel: 978.827.7700 fax: 978.827.7087 e-mail: [email protected]
Student Name_____________________________________________________________________________________________ please print
last (family) name
first name
This confidential form must be returned as soon as possible. Student: Check off the program you are applying to: COLLEGE PREP – SECONDARY SCHOOL LEVEL
ENGLISH AS A SECOND LANGUAGE
CRITICAL SKILLS ACROSS THE CURRICULUM
PREP FOR SUCCESS
IN ENGLISH, MATHEMATICS AND STUDY TECHNIQUES
STUDIO ART
TO THE HUMANITIES TEACHER: The above-named student is applying for admission to Cushing Academy’s Summer Session. Please provide the information requested below and send the completed form via fax, email, or mail to:
Cushing Academy Summer Session Office 39 School Street Ashburnham, Massachusetts 01430
Thank you for your assistance. Name of course in which you instruct the applicant:_______________________________________________________________ Title(s) of primary text(s):____________________________________________________________________________________ ACADEMIC QUALITIES PLEASE EVALUATE THE APPLICANT BY CHECKING THE APPROPRIATE BOXES.
Below Outstanding Good Average average
Poor
N/A
Academic potential
q
q
q
q
q
q
Academic achievement
q
q
q
q
q
q
Effort
q
q
q
q
q
q
Motivation
q
q
q
q
q
q
Willingness to ask for help
q
q
q
q
q
q
Response to Criticism
q
q
q
q
q
q
Class participation
q
q
q
q
q
q
Homework preparation
q
q
q
q
q
q
Comprehension of fundamental principles
q
q
q
q
q
q
Intellectual curiosity
q
q
q
q
q
q
Ability to work independently
q
q
q
q
q
q
Attendance/Punctuality
q
q
q
q
q
q
IF THIS STUDENT HANDS WORK IN LATE, IT WOULD PROBABLY BE BECAUSE THE STUDENT: q Procrastinates
q Is busy with many activities
q Loses the rough draft
q Not applicable, this student’s work is always on time
q Strives for perfection
q Other______________________________________________________________________________ (continued on back)
6
PERSONAL QUALITIES PLEASE EVALUATE THE APPLICANT BY CHECKING THE APPROPRIATE BOXES. Outstanding Good
Average average
Poor
N/A
Integrity
q
q
q
q
q
q
Concern for others
q
q
q
q
q
q
Responsibility
q
q
q
q
q
q
Conduct
q
q
q
q
q
q
Maturity
q
q
q
q
q
q
Sense of humor
q
q
q
q
q
q
Ability to work with peers
q
q
q
q
q
q
Emotional stability
q
q
q
q
q
q
Self-confidence
q
q
q
q
q
q
What is the applicant’s greatest academic strength?
What is the applicant’s greatest academic shortcoming or need?
What is the applicant’s greatest personal strength?
What is the applicant’s greatest personal shortcoming or need?
Please include any additional information about the student below.
I recommend this applicant for admission to the Cushing Academy Summer Session:
q
not at all
q
with reservations
q
mildly
q
strongly
q
enthusiastically
Signature __________________________________________________________________________ Date_______________________________ Name (please print)__________________________________________________________________ Position____________________________ School address_________________________________________________________________________________________________________ School telephone_______________________________________________________________________________________________________ Email address__________________________________________________________________________________________________________
Decisions are made without regard to race, religion, sex, creed, national origin, or any other protected category under applicable law. Cushing Academy has no restrictions on its admission policy regarding race, religion, sex, creed, national origin, or any other protected category under applicable law. Candidates are judged solely on the basis of references, personal interviews, and school program of studies. We seek students who are seriously interested in preparing for college and who indicate they will be mature members of the Academy student body. 7
APPLICATION FOR ADMISSION CUSHING SUMMER SESSION
Mathematics Teacher Recommendation
CUSHING ACADEMY 39 School Street Ashburnham, MA 01430-8000 USA
tel: 978.827.7700 fax: 978.827.7087 e-mail: [email protected]
Student Name_____________________________________________________________________________________________ please print
last (family) name
first name
This confidential form must be returned as soon as possible. Student: Check off the program you are applying to: COLLEGE PREP – SECONDARY SCHOOL LEVEL CRITICAL SKILLS ACROSS THE CURRICULUM IN ENGLISH, MATHEMATICS AND STUDY TECHNIQUES PREP FOR SUCCESS
TO THE MATHEMATICS TEACHER: The above-named student is applying for admission to Cushing Academy’s Summer Session. Please provide the information requested below and send the completed form via fax, email, or mail to:
Cushing Academy Summer Session Office 39 School Street Ashburnham, Massachusetts 01430
Thank you for your assistance. Name of course in which you instruct the applicant:_______________________________________________________________ Title(s) of primary text book(s):________________________________________________________________________________ ACADEMIC QUALITIES PLEASE EVALUATE THE APPLICANT BY CHECKING THE APPROPRIATE BOXES.
Below Outstanding Good Average average
Poor
N/A
Academic potential
q
q
q
q
q
q
Academic achievement
q
q
q
q
q
q
Effort
q
q
q
q
q
q
Motivation
q
q
q
q
q
q
Willingness to ask for help
q
q
q
q
q
q
Response to Criticism
q
q
q
q
q
q
Class participation
q
q
q
q
q
q
Homework preparation
q
q
q
q
q
q
Comprehension of fundamental principles
q
q
q
q
q
q
Intellectual curiosity
q
q
q
q
q
q
Ability to work independently
q
q
q
q
q
q
Attendance/Punctuality
q
q
q
q
q
q
IF THIS STUDENT HANDS WORK IN LATE, IT WOULD PROBABLY BE BECAUSE THE STUDENT: q Procrastinates
q Is busy with many activities
q Loses the rough draft
q Not applicable, this student’s work is always on time
q Strives for perfection
q Other______________________________________________________________________________ (continued on back)
8
PERSONAL QUALITIES PLEASE EVALUATE THE APPLICANT BY CHECKING THE APPROPRIATE BOXES. Outstanding Good
Average average
Poor
N/A
Integrity
q
q
q
q
q
q
Concern for others
q
q
q
q
q
q
Responsibility
q
q
q
q
q
q
Conduct
q
q
q
q
q
q
Maturity
q
q
q
q
q
q
Sense of humor
q
q
q
q
q
q
Ability to work with peers
q
q
q
q
q
q
Emotional stability
q
q
q
q
q
q
Self-confidence
q
q
q
q
q
q
What is the applicant’s greatest academic strength?
What is the applicant’s greatest academic shortcoming or need?
What is the applicant’s greatest personal strength?
What is the applicant’s greatest personal shortcoming or need?
Please include any additional information about the student below.
I recommend this applicant for admission to the Cushing Academy Summer Session:
q
not at all
q
with reservations
q
mildly
q
strongly
q
enthusiastically
Signature __________________________________________________________________________ Date_______________________________ Name (please print)__________________________________________________________________ Position____________________________ School address_________________________________________________________________________________________________________ School telephone_______________________________________________________________________________________________________ Email address__________________________________________________________________________________________________________
Decisions are made without regard to race, religion, sex, creed, national origin, or any other protected category under applicable law. Cushing Academy has no restrictions on its admission policy regarding race, religion, sex, creed, national origin, or any other protected category under applicable law. Candidates are judged solely on the basis of references, personal interviews, and school program of studies. We seek students who are seriously interested in preparing for college and who indicate they will be mature members of the Academy student body. 9
APPLICATION FOR ADMISSION CUSHING SUMMER SESSION
Transcript Release
CUSHING ACADEMY 39 School Street Ashburnham, MA 01430-8000 USA
tel: 978.827.7700 fax: 978.827.7087 e-mail: [email protected]
This form and your transcript from your present school must be returned to the Summer Session Office as soon as possible. TO THE STUDENT Please fill out your name and have your parent(s) sign in the space provided. Then take this form to your school’s principal or guidance counselor to authorize the release of your academic records to Cushing Academy.
Student name (please print)______________________________________________________________________________________________ LAST (FAMILY) NAME FIRST NAME
I consent to the release of my child’s school records to Cushing Academy.
Parent Signature_______________________________________________________________________________________________________ TO THE SCHOOL REGISTRAR The above-named student is applying for admission to Cushing Academy’s Summer Session. Please submit high school or middle school academic information including standardized test results, courses taken and grades received. Please address these materials to: Cushing Academy Summer Session Office 39 School Street Ashburnham, Massachusetts 01430
APPLICATION FOR ADMISSION CUSHING SUMMER SESSION
Credit Card Payment Form
Please fax this form to:
CUSHING ACADEMY 39 School Street Ashburnham, MA 01430-8000 USA
tel: 978.827.7700 fax: 978.827.7087 e-mail: [email protected]
Cushing Academy Summer Session
978.827.7087 or mail the form to:
Cushing Academy
Summer Session 39 School Street Ashburnham, Massachusetts 01430-8000 USA AUTHORIZATION I authorize Cushing Academy Summer Session to charge the US $60 processing fee to: q
American Express
q
VISA
q
MasterCard
__________________________________________________________ __________________________________________________________ CARDHOLDER’S NAME—PLEASE PRINT
CREDIT CARD NUMBER
__________________________________________________________ __________________________________________________________ CARDHOLDER’S SIGNATURE
EXPIRATION DATE (MONTH/YEAR)
10
T O L E A R N M O R E A B O U T S U M M E R S E S S I O N AT C U S H I N G :
MARGARET LEE DIRECTOR, CUSHING SUMMER SESSION Cushing Academy 39 School Street Ashburnham, MA 01430
CUSHING.ORG/SU M M E R
978.827.7700 [email protected]
Checklist for Applying to Cushing Summer Session Programs The Cushing Summer Session Office looks forward to receiving your application for one of our programs. Applications are reviewed on a rolling basis until all places are filled. To ensure a space in this summer’s program, your application should be completed as soon as possible. THE FOLLOWING ITEMS ARE REQUIRED TO COMPLETE YOUR APPLICATION ALL STUDENTS NEED TO COMPLETE: q
1. Student Application: Please complete this form yourself, and check off the academic program for which you are applying.
q
2. Parent Section: This section, on the back of the Student Application, is for your parents so that we can get all the information we need to be in touch with them about your summer.
q
3. Personal Essay: Please answer one of the three questions to help us get to know you better.
q 4. Find the program you are applying to in the list below, and make sure you have completed and checked off the necessary forms to send back. q
5. $60 processing fee: Send the processing fee to Cushing Academy Summer Session, PO Box 8000, Ashburnham, MA 01430. Your application will not be considered until the processing fee is received at Cushing.
q
6. Please include a recent photograph.
COLLEGE PREP AND CRITICAL SKILLS APPLICANTS q
Humanities Teacher Recommendation: Please give this recommendation form to your current English teacher.
q
Mathematics Teacher Recommendation: Please give this recommendation form to your current mathematics teacher.
q
Transcript Release: Fill out this form, have your parents sign it, and then give it to the registrar at your current school.
ENGLISH AS A SECOND LANGUAGE* q
Humanities Teacher Recommendation: Please give this recommendation form to your current English or E.S.L. teacher.
q
Transcript Release: Fill out this form, have your parents sign it, and then give it to the registrar at your current school. *Students applying to the Integrated Skills for Advanced Students Preparing for TOEFL iBT must provide proof of advanced language proficiency.
PREP FOR SUCCESS APPLICANTS q
Humanities Teacher Recommendation: Please give this recommendation form to your current English or E.S.L. teacher. or
q
Mathematics Teacher Recommendation: If you are applying for Prep for Success Mathematics or Robotics, give this recommendation form to your current mathematics teacher.
q
Transcript Release: Fill out this form, have your parents sign it, and then give it to the registrar at your current school.
STUDIO ART APPLICANTS q
Humanities Teacher Recommendation: Please give this recommendation form to your current art teacher.
q
Transcript Release: Fill out this form, have your parents sign it, and then give it to the registrar at your current school.
1
APPLICATION FOR ADMISSION CUSHING SUMMER SESSION
Student Application
CUSHING ACADEMY 39 School Street Ashburnham, MA 01430-8000 USA
tel: 978.827.7700 fax: 978.827.7087 e-mail: [email protected]
TO THE APPLICANT This application should be filled out promptly and returned via fax, mail, or e-mail to the Cushing Academy Summer Session Office with the required, non-refundable application fee of US $60. If you choose to fax the application, please include the Credit Card Payment Form (on page 10 of application) to secure payment of the application fee. Applications are acted upon by the Admission Committee when they are complete. Student Name (as it appears on passport)_______________________________________________________________________
last (family) name
first name
middle name
Address___________________________________________________________________________________________________
number an d street
city
state or country
zip code
Home phone ___________________________________________ Student Cell________________________________________ Student e-mail_____________________________________________________________________________________________ Birthdate_________________________ q Male q Female
Student's age_______________________________________
month/day/year
Citizenship_____________________________________________ Country of birth_____________________________________ Name of present school ___________________________________ Current grade_______________________________________ From whom or how did you learn about Cushing Academy?_________________________________________________________
Please select the desired academic program (check only one triangle below): r ACADEMIC PROGRAMS FOR STUDENTS AGES 12–13:
r ACADEMIC PROGRAMS FOR STUDENTS AGES 14–18: (check only one circle below)
PREP FOR SUCCESS CORE COURSES
q LITERATURE AND WRITING q MATHEMATICS q ROBOTICS q ENGLISH AS A SECOND LANGUAGE
COLLEGE PREP (choose one course from the section below)
(choose one course from the section below)
CRITICAL SKILLS ACROSS THE CURRICULUM in English, Mathematics and Study Techniques
q RESPONDING TO LITERATURE THROUGH
r PROGRAM FOR STUDENTS AGES 13–18:
q STUDIO ART AND
PORTFOLIO PREPARATION
CRITICAL AND CREATIVE WRITING
q UNITED STATES HISTORY q ALGEBRA I q GEOMETRY q ALGEBRA II q STATISTICS q PRECALCULUS q BIOLOGY q CHEMISTRY q PHYSICS q COLLEGE ADVISING WORKSHOP
ENGLISH AS A SECOND LANGUAGE (choose one course from the section below)
q STANDARD ESL (LISTENING
SPEAKING/READING/WRITING)
q INTEGRATED SKILLS FOR
ADVANCED STUDENTS
PREPARING FOR TOEFL IBT
2
PARENT INFORMATION Father’s name_____________________________________________
Mother’s name____________________________________________
Home address_____________________________________________
Home address_____________________________________________
________________________________________________________
________________________________________________________
Home phone______________________________________________
Home phone______________________________________________
Cell phone _______________________________________________
Cell phone _______________________________________________
Business phone___________________________________________
Business phone___________________________________________
Business fax______________________________________________
Business fax______________________________________________
E-mail address____________________________________________
E-mail address____________________________________________
Occupation_______________________________________________
Occupation_______________________________________________
If parents are separated or divorced, who is the custodial parent? ______________________________________________________________ To whom should reports be sent?_________________________________________________________________________________________ To whom should bills be sent?____________________________________________________________________________________________ PERSON TO BE CONTACTED IN CASE OF EMERGENCY IF PARENT/GUARDIAN CANNOT BE REACHED (IF POSSIBLE, INTERNATIONAL STUDENTS SHOULD LIST A CONTACT IN THE UNITED STATES): Name________________________________________________________________________________________________________________
last (family) name
first name
middle name
Address______________________________________________________________________________________________________________
number and street
city
state or country
zip code
Primary phone ______________________________________________ Cell phone________________________________________________ Work phone _________________________________________________ E-mail___________________________________________________
AUTHORIZATION I authorize this application and assume responsibility for tuition and other expenses. I understand that my child will be subject to all school regulations. In the event of an emergency, I authorize medical treatment as deemed necessary by competent health personnel. I also understand that in the event of early withdrawal or dismissal of my child from the school, the remaining tuition is forfeited Information regarding background checks, health care and discipline policies, as well as procedures for filing grievances, may be requested.
Parent signature ________________________________________________________________________ Date__________________________
PAYMENT Please make certain the application is complete and the processing fee is included by checking one of the following: q
Enclosed please find my check or money order for payment of the $60 processing fee. Make checks payable to: Cushing Academy Summer Session.
q
Enclosed please find my Credit Card Payment Form (on page 10 of application).
Please note: Your application will not be considered until the processing fee is received by Cushing. Decisions are made without regard to race, religion, sex, creed, national origin, or any other protected category under applicable law. Cushing Academy has no restrictions on its admission policy regarding race, religion, sex, creed, national origin, or any other protected category under applicable law. Candidates are judged solely on the basis of references, personal interviews, and school program of studies. We seek students who are seriously interested in preparing for college and who indicate they will be mature members of the Academy student body.
3
APPLICATION FOR ADMISSION CUSHING SUMMER SESSION
Personal Essay
CUSHING ACADEMY 39 School Street Ashburnham, MA 01430-8000 USA
tel: 978.827.7700 fax: 978.827.7087 e-mail: [email protected]
At Cushing we try to learn as much about each individual student as we can. Please take a few minutes to help us get to know you better by answering one of the questions below. PLEASE WRITE IN YOUR OWN HANDWRITING BELOW OR PRINT OUT YOUR RESPONSE ON A SEPARATE SHEET OF PAPER AND ATTACH IT TO THIS SHEET.
CHOOSE ONE: What do you think would be valuable for us to know about you and why? Why are you applying to Summer Session? What do you hope to achieve? Tell us about a time that you were challenged by something. (What was it? What did you do? What was the outcome?) _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ (continued on back)
4
(Personal Essay continued) _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________
Student’s signature__________________________________________________________ Date_______________________________________ Name (please print)_____________________________________________________________________________________________________
Decisions are made without regard to race, religion, sex, creed, national origin, or any other protected category under applicable law. Cushing Academy has no restrictions on its admission policy regarding race, religion, sex, creed, national origin, or any other protected category under applicable law. Candidates are judged solely on the basis of references, personal interviews, and school program of studies. We seek students who are seriously interested in preparing for college and who indicate they will be mature members of the Academy student body.
5
APPLICATION FOR ADMISSION CUSHING SUMMER SESSION
Humanities Teacher Recommendation
CUSHING ACADEMY 39 School Street Ashburnham, MA 01430-8000 USA
tel: 978.827.7700 fax: 978.827.7087 e-mail: [email protected]
Student Name_____________________________________________________________________________________________ please print
last (family) name
first name
This confidential form must be returned as soon as possible. Student: Check off the program you are applying to: COLLEGE PREP – SECONDARY SCHOOL LEVEL
ENGLISH AS A SECOND LANGUAGE
CRITICAL SKILLS ACROSS THE CURRICULUM
PREP FOR SUCCESS
IN ENGLISH, MATHEMATICS AND STUDY TECHNIQUES
STUDIO ART
TO THE HUMANITIES TEACHER: The above-named student is applying for admission to Cushing Academy’s Summer Session. Please provide the information requested below and send the completed form via fax, email, or mail to:
Cushing Academy Summer Session Office 39 School Street Ashburnham, Massachusetts 01430
Thank you for your assistance. Name of course in which you instruct the applicant:_______________________________________________________________ Title(s) of primary text(s):____________________________________________________________________________________ ACADEMIC QUALITIES PLEASE EVALUATE THE APPLICANT BY CHECKING THE APPROPRIATE BOXES.
Below Outstanding Good Average average
Poor
N/A
Academic potential
q
q
q
q
q
q
Academic achievement
q
q
q
q
q
q
Effort
q
q
q
q
q
q
Motivation
q
q
q
q
q
q
Willingness to ask for help
q
q
q
q
q
q
Response to Criticism
q
q
q
q
q
q
Class participation
q
q
q
q
q
q
Homework preparation
q
q
q
q
q
q
Comprehension of fundamental principles
q
q
q
q
q
q
Intellectual curiosity
q
q
q
q
q
q
Ability to work independently
q
q
q
q
q
q
Attendance/Punctuality
q
q
q
q
q
q
IF THIS STUDENT HANDS WORK IN LATE, IT WOULD PROBABLY BE BECAUSE THE STUDENT: q Procrastinates
q Is busy with many activities
q Loses the rough draft
q Not applicable, this student’s work is always on time
q Strives for perfection
q Other______________________________________________________________________________ (continued on back)
6
PERSONAL QUALITIES PLEASE EVALUATE THE APPLICANT BY CHECKING THE APPROPRIATE BOXES. Outstanding Good
Average average
Poor
N/A
Integrity
q
q
q
q
q
q
Concern for others
q
q
q
q
q
q
Responsibility
q
q
q
q
q
q
Conduct
q
q
q
q
q
q
Maturity
q
q
q
q
q
q
Sense of humor
q
q
q
q
q
q
Ability to work with peers
q
q
q
q
q
q
Emotional stability
q
q
q
q
q
q
Self-confidence
q
q
q
q
q
q
What is the applicant’s greatest academic strength?
What is the applicant’s greatest academic shortcoming or need?
What is the applicant’s greatest personal strength?
What is the applicant’s greatest personal shortcoming or need?
Please include any additional information about the student below.
I recommend this applicant for admission to the Cushing Academy Summer Session:
q
not at all
q
with reservations
q
mildly
q
strongly
q
enthusiastically
Signature __________________________________________________________________________ Date_______________________________ Name (please print)__________________________________________________________________ Position____________________________ School address_________________________________________________________________________________________________________ School telephone_______________________________________________________________________________________________________ Email address__________________________________________________________________________________________________________
Decisions are made without regard to race, religion, sex, creed, national origin, or any other protected category under applicable law. Cushing Academy has no restrictions on its admission policy regarding race, religion, sex, creed, national origin, or any other protected category under applicable law. Candidates are judged solely on the basis of references, personal interviews, and school program of studies. We seek students who are seriously interested in preparing for college and who indicate they will be mature members of the Academy student body. 7
APPLICATION FOR ADMISSION CUSHING SUMMER SESSION
Mathematics Teacher Recommendation
CUSHING ACADEMY 39 School Street Ashburnham, MA 01430-8000 USA
tel: 978.827.7700 fax: 978.827.7087 e-mail: [email protected]
Student Name_____________________________________________________________________________________________ please print
last (family) name
first name
This confidential form must be returned as soon as possible. Student: Check off the program you are applying to: COLLEGE PREP – SECONDARY SCHOOL LEVEL CRITICAL SKILLS ACROSS THE CURRICULUM IN ENGLISH, MATHEMATICS AND STUDY TECHNIQUES PREP FOR SUCCESS
TO THE MATHEMATICS TEACHER: The above-named student is applying for admission to Cushing Academy’s Summer Session. Please provide the information requested below and send the completed form via fax, email, or mail to:
Cushing Academy Summer Session Office 39 School Street Ashburnham, Massachusetts 01430
Thank you for your assistance. Name of course in which you instruct the applicant:_______________________________________________________________ Title(s) of primary text book(s):________________________________________________________________________________ ACADEMIC QUALITIES PLEASE EVALUATE THE APPLICANT BY CHECKING THE APPROPRIATE BOXES.
Below Outstanding Good Average average
Poor
N/A
Academic potential
q
q
q
q
q
q
Academic achievement
q
q
q
q
q
q
Effort
q
q
q
q
q
q
Motivation
q
q
q
q
q
q
Willingness to ask for help
q
q
q
q
q
q
Response to Criticism
q
q
q
q
q
q
Class participation
q
q
q
q
q
q
Homework preparation
q
q
q
q
q
q
Comprehension of fundamental principles
q
q
q
q
q
q
Intellectual curiosity
q
q
q
q
q
q
Ability to work independently
q
q
q
q
q
q
Attendance/Punctuality
q
q
q
q
q
q
IF THIS STUDENT HANDS WORK IN LATE, IT WOULD PROBABLY BE BECAUSE THE STUDENT: q Procrastinates
q Is busy with many activities
q Loses the rough draft
q Not applicable, this student’s work is always on time
q Strives for perfection
q Other______________________________________________________________________________ (continued on back)
8
PERSONAL QUALITIES PLEASE EVALUATE THE APPLICANT BY CHECKING THE APPROPRIATE BOXES. Outstanding Good
Average average
Poor
N/A
Integrity
q
q
q
q
q
q
Concern for others
q
q
q
q
q
q
Responsibility
q
q
q
q
q
q
Conduct
q
q
q
q
q
q
Maturity
q
q
q
q
q
q
Sense of humor
q
q
q
q
q
q
Ability to work with peers
q
q
q
q
q
q
Emotional stability
q
q
q
q
q
q
Self-confidence
q
q
q
q
q
q
What is the applicant’s greatest academic strength?
What is the applicant’s greatest academic shortcoming or need?
What is the applicant’s greatest personal strength?
What is the applicant’s greatest personal shortcoming or need?
Please include any additional information about the student below.
I recommend this applicant for admission to the Cushing Academy Summer Session:
q
not at all
q
with reservations
q
mildly
q
strongly
q
enthusiastically
Signature __________________________________________________________________________ Date_______________________________ Name (please print)__________________________________________________________________ Position____________________________ School address_________________________________________________________________________________________________________ School telephone_______________________________________________________________________________________________________ Email address__________________________________________________________________________________________________________
Decisions are made without regard to race, religion, sex, creed, national origin, or any other protected category under applicable law. Cushing Academy has no restrictions on its admission policy regarding race, religion, sex, creed, national origin, or any other protected category under applicable law. Candidates are judged solely on the basis of references, personal interviews, and school program of studies. We seek students who are seriously interested in preparing for college and who indicate they will be mature members of the Academy student body. 9
APPLICATION FOR ADMISSION CUSHING SUMMER SESSION
Transcript Release
CUSHING ACADEMY 39 School Street Ashburnham, MA 01430-8000 USA
tel: 978.827.7700 fax: 978.827.7087 e-mail: [email protected]
This form and your transcript from your present school must be returned to the Summer Session Office as soon as possible. TO THE STUDENT Please fill out your name and have your parent(s) sign in the space provided. Then take this form to your school’s principal or guidance counselor to authorize the release of your academic records to Cushing Academy.
Student name (please print)______________________________________________________________________________________________ LAST (FAMILY) NAME FIRST NAME
I consent to the release of my child’s school records to Cushing Academy.
Parent Signature_______________________________________________________________________________________________________ TO THE SCHOOL REGISTRAR The above-named student is applying for admission to Cushing Academy’s Summer Session. Please submit high school or middle school academic information including standardized test results, courses taken and grades received. Please address these materials to: Cushing Academy Summer Session Office 39 School Street Ashburnham, Massachusetts 01430
APPLICATION FOR ADMISSION CUSHING SUMMER SESSION
Credit Card Payment Form
Please fax this form to:
CUSHING ACADEMY 39 School Street Ashburnham, MA 01430-8000 USA
tel: 978.827.7700 fax: 978.827.7087 e-mail: [email protected]
Cushing Academy Summer Session
978.827.7087 or mail the form to:
Cushing Academy
Summer Session 39 School Street Ashburnham, Massachusetts 01430-8000 USA AUTHORIZATION I authorize Cushing Academy Summer Session to charge the US $60 processing fee to: q
American Express
q
VISA
q
MasterCard
__________________________________________________________ __________________________________________________________ CARDHOLDER’S NAME—PLEASE PRINT
CREDIT CARD NUMBER
__________________________________________________________ __________________________________________________________ CARDHOLDER’S SIGNATURE
EXPIRATION DATE (MONTH/YEAR)
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T O L E A R N M O R E A B O U T S U M M E R S E S S I O N AT C U S H I N G :
MARGARET LEE DIRECTOR, CUSHING SUMMER SESSION Cushing Academy 39 School Street Ashburnham, MA 01430
CUSHING.ORG/SU M M E R
978.827.7700 [email protected]
