Honors Academy 2004 Application

Sponsored by Oglala Lakota Collegeís Model Institutions for Excellence Program, DIAL Interactive Learning Campus Grant, and Oceti Sakowin Education Consortium Program on the SDSM&T campus in Rapid City, South Dakota

 

HONORS ACADEMY Summer Program 2004

Cohort XI

June 6, 2004-July 16, 2004

Application for 2004 Summer Honors Program

 

The Honors Academy is a residential six-week, college preparation experienced designed for students who desire to excel in the areas of math, science, engineering and information technology

ELIGIBILITY Ė Students entering the ninth grade by August 2004 with a 3.0 GPA.

Students selected to participate in the program will be required to commit to residing on the South Dakota School of Mines and Technology (SDSM&T) campus for the entire six-week period, over four consecutive years.

COST Ė Support will be provided to cover studentís instructional costs, room and board, books and supplies for students selected for the program.

APPLICATION PROCEDURE Ė

v The student shall have thoroughly completed all sections of the application, including personal information, questions 1-16 and the medical release information on the final page. Incomplete applications will NOT be accepted.

v Studentís math and science teachers MUST complete at least one of the recommendation forms. No exceptions. Other recommendation forms can be completed by counselors, principal, other teachers, etc.

v Neatness of the application is important.

v Student selection will be based upon 1 questions (30%), academic and attendance record (30%), and teacher recommendations (40%).

APPLICATION DEADLINE Ė This application must be returned by April 16, 2004. Applications returned after this time will not be accepted for consideration into this summerís Honors Academy. Applicants will be notified during the first week of May 2004 about the status of their application.

Completed applications can be mailed to: Faxed: (605) 455-2603 or mailed to:

Susan Conrad

Oglala Lakota College

P.O. Box 490 Kyle, SD 57752

If you have any questions, please contact Susan Conrad at (605) 455-6094 email: sconrad@olc.edu or Stacy Phelps (605) 455-6001 email: sphelps@olc.edu

Student participants will be required to maintain a GPA of 3.0 and complete academic year activities in order to continue in the program each summer.

 

 

STUDENT APPLICATION

 

Date:_____________________ Present Grade:_________________________

1. Applicantís Name:______________________________________________

2. Parent/Guardianís Name:________________________________________

3. Home Address: ________________________________________________

4. Telephone: _____________________ Email:_______________________

5. Date of Birth:_____________Social Security #:_______________________

6. Gender: M F

7. Ethnicity: Amer. Ind./Alaskan Native White Black Hispanic Asian/Pacific

Please send in a copy of your blood degree document.

 

8. School: ____________________________________________________

9. Address:____________________________________________________

10. Guidance Counselorís Name: ____________________________________

11. Do you currently qualify for your schoolís Free or Reduced (National School Lunch Program) Lunch Program (this is not used as an admission requirement for Honors Program)? Yes †††††††††† No

 

For the remaining questions please use additional paper as needed and include with application.

 

12. What two school subjects do you like best and why?

a. ________________________________ b.____________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

 

 

 

13. Please list any extra-curricular activities, academic organizations and activities you participate in for example, sports, student organizations, cultural activities (language, dancing, drum groups), or community volunteerism.

________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________

 

14. Please list any awards and/or recognition you have received and the date: (honor rolls, science fairs, most valuable player, etc.)

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________≠≠≠≠≠_______

15. Please provide a brief description of your background.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________

16. Explain what you find most interesting about math, science, engineering and information technology.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

17. What are your career goals and how do you think your participation in the program will benefit you in your preparation for these goals?

________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

No application is complete unless it includes a most recent report card or transcript, blood degree document, and all signatures that are necessary.


MATH OR SCIENCE TEACHER RECOMMENDATION FORM

v Two recommendation forms are required.

Teachers: Please answer the following questions about the Honors Academy Summer Program applicant as you know them.

1. What are the studentís academic strengths?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. How would you describe the studentís learning style?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. What will this student contribute to the Honors Academy Summer Program?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Why do you recommend this student for participation in the Honors Academy Summer Program?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Teacherís Signature____________________________________________Date_________________


OTHER RECOMMENDATION FORM

v Two recommendation forms are required.

Please answer the following questions about the Honors Academy Summer Program applicant as you know them.

5. What are the studentís academic strengths?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6. How would you describe the studentís learning style?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

7. What will this student contribute to the Honors Academy Summer Program?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

8. Why do you recommend this student for participation in the Honors Academy Summer Program?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Teacherís Signature____________________________________________Date_________


Parent's Permission/Release/Medical Treatment Consent Form

Honors Academy Summer Program THIS IS A MEDICAL CONSENT RELEASE FORM. This is also a release for my son/daughter's likeness and name to be used in various promotional materials. PLEASE READ CAREFULLY.

I give my permission for my son/daughter, __________________________, to participate in the Honors Academy Summer Program activities including accessing Internet and World Wide Web (www) resources. I also give my permission to my son/daughter's school to release information from his/her student questionnaires, evaluations, testing and transcripts to the Honors Academy Summer Program Office. It is my understanding that only summary statistics will be used from these forms and that individual student information will be considered confidential. The Honors Academy Summer Program staff, to help determine student progress for the Honors Academy Summer Program evaluation, uses these forms.

 

In addition, I grant permission to the Honors Academy Summer Program staff to use my son/daughter's name and picture on any news release, promotional release including WWW pages, or news articles associated with Honors Academy Summer Program.

 

In the event my son/daughter, a minor, becomes ill or sustains an injury while in the care or under supervision of the Director or Advisors of the Honors Academy Summer Program any of its officers or leaders are given permission to administer first aid, I _____________________ parent/legal guardian, do hereby authorize the Honors Academy Summer Program staff as agents for the undersigned to consent to give an x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by a Medical Doctor.

 

I understand that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, and remains in effect for all activities in conjunction with the Honors Academy Summer Program. I understand the Honors Academy Summer Program staff will contact me as soon as possible in the event my son/daughter has any illness or accident requiring medical care, but give this consent and authorization in the event of an emergency or inability to reach me.

 

I agree to release and hold harmless the Honors Academy Summer Program organization, its officers or leaders, the State of South Dakota, the South Dakota Board of Regents, or the South Dakota School of Mines and Technology and/or its officers and leaders for any medical or other expenses incurred in the care of my son/daughter.

 

Signature of Parent/Guardian _______________________________________________Date___________

Participant's Signature_____________________________________________________ Date___________

Family Doctor___________________________________________________________________________

Address__________________________________________________ Phone________________________

Parent's Phone Numbers__________________________________________________________________

Home ††††††††††††††††††††††††††††††††††††††††††††††††††† Work

Emergency_____________________________________________________________________________

Parent's Address________________________________________________________________________

Date of Last Tetanus Shot_________________________________________________________________

Allergic to______________________________________________________________________________

 

In selecting individuals for participation and otherwise in the administration of this project, Honors Academy Summer Program will not discriminate on the grounds of race, creed, sex, color, age, handicap or national origin of any applicant.

Application Checklist: Did you complete and include the following documents?

______Student Application

______Blood Degree Document

______Math and Science Teacher Recommendation Form

______Other Recommendation Form

______Most recent transcripts or school report card

______Complete and Signed Parent's Permission/Release/Medical Treatment Consent Form