Application for fall 2015


Part 4 This form should be completed by a school counselor and submitted with an



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Part 4

This form should be completed by a school counselor and submitted with an official high school transcript and copies of all SAT I or ACT score reports available for the applicant. The student should provide the information in the “Applicant” section and give the form to the school counselor completing the form. The counselor should return the form to the student, along with an official transcript and copies of exam score reports, in a sealed envelope.



Applicant

Applicant name

     

     

     







Last

First

Middle




Permanent home address

     







Number and Street







              




City State ZIP Code




Permanent home phone

    /      

Date of birth

     







Area Code/Number




Month/Day/Year



















School Counselor

Counselor name

     

     

     




Title

First

Last

Position

     

School

     

School address

     

Counselor email

     

Counselor phone

    /      

School CEEB/ACT code

     

May we contact you with information about Excel in the future?

Yes No

In comparison to other college preparatory students at your school, the applicant’s course selection is:

Most demanding. Demanding. Average. Less than demanding.

The student ranks

     

in a class of

     

and has a cumulative grade point average of

     

.




This class ranking covers the period from

     

to

     

. Anticipated graduation date

     




If precise rank is not available, please indicate rank to the nearest tenth from the top

     




Senior class average GPA

     

Percentage of the class planning to attend a four-year college

     

%

List scores from any SAT I or ACT exams that the applicant has taken. Please attach copies of score reports if available.

SAT I CR

     

M

     

W

     




Date taken

     




SAT I CR

     

M

     

W

     




Date taken

     




SAT I CR

     

M

     

W

     




Date taken

     




ACT Composite

     




Date taken

     




ACT Composite

     




Date taken

     




ACT Composite

     




Date taken

     




Courses currently in progress:

     




     




     




     




     




     




     




     







Has the applicant ever been found responsible for a disciplinary violation at your school from 9th grade forward, whether related to academic or behavioral misconduct that resulted in probation, suspension, removal or expulsion from your institution?

Yes No

To your knowledge, has the applicant ever been convicted of a misdemeanor, felony, or other crime, or have a court case pending against him or her at this time?

Yes No

If you answered yes to either or both questions, please give the approximate date of each incident and explain the circumstances in the space below.




     

     

     

     

     




Counselor signature







Date

     

Academic

Recommendation
Deadline: January 16, 2015 Part 5

Applicant

This recommendation must come from a teacher who has taught you an academic subject (for example, English, foreign language, math, science, or social studies). Print your name below and give the form to the recommender. Inform your recommender you are applying for admission to Union University and/or CBU. That person should return the form to you in a sealed envelope for you to submit with your completed application.

Applicant name

     

     

     




Last

First

Middle

I WAIVE my right to access this form in the future and I understand I will never be able to see its contents.

I DO NOT WAIVE my right to access this form in the future and I may someday choose to see it once I enroll in college.

Applicant signature







Date

     




Academic Recommender

The student named above is applying for the Excel Leadership and Scholarship Initiative and admission to Union University and/or CBU. Excel is a Christian urban leadership development and scholarship initiative with a four-part strategy: (1) Locally recruits and selects a diverse, multicultural cadre of Memphis’ most promising urban student leaders; (2) Intensively trains this group of students in the months prior to college, equipping them to support each other, grow in leadership, succeed academically, and grow as service-minded leaders and agents of transformation; (3) Helps facilitate the Excel scholarship and send the teams to Union University in Jackson, or CBU in Memphis for four years of Christian education at a highly diverse liberal arts college; and (4) Provides strong campus support and ongoing leadership development experiences to nurture these young people as they find their vocation and grow into the next generation of community leaders.

We are seeking young people who are passionate about learning, eager to foster intercultural communication and relationships, willing to step out of their comfort zones, committed to serving those around them, and ready to make a difference on the college campus and in their communities at home. The selection process also places high value on students' teamwork, critical thinking, and communication skills, as well as on their academic potential. In seeking to identify qualified students for this extraordinary opportunity, we value your candid evaluation of the applicant.



How long have you known the applicant and in what context?

     

     

List the academic courses that you have taught this student, noting for each the applicant’s year in school (10th, 11th, 12th, etc.) and the level of course difficulty (AP, honors, IB, elective, etc.). If you have not taught the student an academic subject, do not complete this form (the student could still ask you to complete the community recommendation instead).


     

     

What are the first words that come to your mind to describe the applicant?

     

     

Compared to other college bound students you have worked with, how would you rate this student in terms of:

No basis




Below average

Average

Good
(above average)


Very good (well above average)

Excellent
(top 10%)


Outstanding (top 5%)

One of the
top few encountered
in my career




Leadership

















Academic achievement

















Intellectual promise

















Quality of writing

















Creative, original thought

















Productive class discussion

















Respect accorded by faculty

















Disciplined work habits

















Maturity

















Motivation

















Integrity

















Reaction to setbacks

















Concern for others

















Self-confidence

















Initiative, independence

















OVERALL















Please return both pages of this form to the applicant in a sealed envelope so that s/he can mail it by the January 16, 2015 application deadline. If you choose, you may include a recommendation letter as well.

Teacher name

     

     

     




Title

First

Last

Position

     

School

     




Phone

    /      




    /      




Daytime




Evening

Email

     










May we contact you with information about Excel in the future?

Yes No







Teacher signature







Date

     

Community

Recommendation

Deadline: January 16, 2015

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