PREP HIGH SCHOOL ACADEMY Student Application Form

PREP HS 2016 PREP HIGH SCHOOL ACADEMY Student Application Form PREP is administered by the College of Engineering, New Mexico State University Pag...
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PREP HS 2016

PREP HIGH SCHOOL ACADEMY

Student Application Form

PREP is administered by the College of Engineering, New Mexico State University

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PREP HS 2016

PREP High School Academy Overview June 19-30, 2016 What is PREP? The PREP High School Academy is an academic and residential program designed to introduce students who have completed grades 9-11 to the concepts of STEM, with a focus on engineering, through project-based learning. Each day students will participate in activities that will enhance their skills in many STEM areas. Sessions will be led by New Mexico State University faculty and staff. There is no charge to participate in the program, however participation is limited to selected students.

Who can attend PREP? 

Students who have completed 9th, 10th or 11th grade that are interested in science, technology, engineering or mathematics

Where is PREP held? PREP will be held on the New Mexico State University campus in Las Cruces, NM, from June 19 to June 30. All students will be provided with room and board. It is mandatory for all participants to stay in the provided housing for the duration of the camp. Parents are responsible for the student’s transportation to and from the camp.

How to apply:  

Student (and Parent/Guardian) need to complete the attached Student Application Form. Submit your application form with all other required documentation: Mailing Address: Tracey O’Neil-PREP College of Engineering New Mexico State University MSC 3449, P.O. Box 30001 Las Cruces, NM 88003

Delivery Address: Tracey O’Neil-PREP College of Engineering New Mexico State University Goddard Hall Rm. 310 1100 S. Horseshoe Las Cruces, NM 88003

The deadline to submit your application is March 31, 2016. Include all application documents together in one packet and please DO NOT staple your application. Only complete applications will be considered. You will NOT receive notification of an incomplete application. Selections for the Academy will be made by April 15, 2016. You will receive notification, via mail, on acceptance status. If you have questions or need additional information, contact us at (575) 646-2913 or [email protected]

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PREP High School Academy Rules and Policies PREP Rules and Policies The following is a list of rules and prohibited conduct intended to assist in providing for the health, safety and social well-being of everyone attending the PREP High School Academy. Any reasonable suspicion that a student has engaged in such prohibited conduct, or attempted conduct, or violation of any rule will result in the immediate dismissal from the program.  

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Students are expected to obey dorm rules and instructions given by PREP staff or instructors. Students are expected to adhere to the dress code at all times. Undergarments should not be showing (i.e. no spaghetti straps or baggy pants), no clothing with offensive logos, messages, or alcohol or drug references, and all clothing should be an appropriate length not showing excessive skin. Students are expected to actively participate in all program classes and activities. Students are not to walk around campus except in groups and accompanied by the PREP staff and insructor. Each student must make sure that their PREP mentor knows where he or she is at all times (ask to exit to the bathroom or other areas away from group). Students are required to be present and actively participating in their assigned activities at all times. Disruptive behavior in classes or on field trips/excursions and unexcused absences from any scheduled activity will not be permitted. Dangerous or threatening conduct, disrespectful behavior, bullying (persistent, offensive, abusive, intimidating, or insulting behavior, which makes the recipient feel upset, threatened, humiliated, or vulnerable) and hazing (conduct that causes or intends to cause psychological, emotional, or physical harm to any person) will not be permitted. Possessing, using, storing, or transporting firearms, other weapons, explosives, smoke bombs, fireworks, ammunition, or dangerous chemicals are prohibited. Relatives and friends are not permitted to pick up students during the program. Visitors during the program is not allowed. Students must keep all cellphones, tablets, music players, hand-held gaming devices, and other electronics in their dorm room. Electronic devices are not permitted in classes and students are responsible for the location and safe keeping of these devices. All students are to be in their assigned dorm room by 9:00 p.m. and lights out at 9:30 p.m. No visitors allowed.

Inquiries If you have any questions or comments, please call the PREP Office at (575) 646-2913 or (575) 646-7852.

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PREP High School Academy Contact Information PREP Academy Program Manager Tracey O’Neil Email: [email protected]

Mailing Address NMSU PREP College of Engineering New Mexico State University MSC 3449, PO Box 30001 Las Cruces, NM 88003 Phone: 575-646-7852

Physical Location 1100 South Horseshoe Goddard Hall, Room 310 Las Cruces, NM 88003

Phone: 575-646-2913 Fax: 575-646-5440

PREP Office

 PREP Classrooms



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PREP High School Academy Student Application Form

Deadline: Postmarked on or before March 31, 2016 Student Information First Name

Middle Initial

DOB (MM/DD/YYYY)

/

Age

Gender Male☐

/

Mailing Address

Last Name Email Address

Female☐

City

Ethnicity American Indian☐ Caucasian☐ African American☐ Hispanic☐

State

Asian/Pacific Islander☐ Other ☐

Zip Code Adult T-Shirt Size S ☐ M ☐ L ☐ XL☐

Parent/Guardian Information Mother’s Full Name

Work Phone #

Home Phone #

Home and E-Mail Address

Cell Phone # Contact 1st ☐ 2nd ☐

Father’s Full Name

Work Phone #

Home Phone #

Home and E-Mail Address

Cell Phone # Contact 1st ☐ 2nd ☐

Additional Emergency Contact Full Name of Contact

Relationship

Phone #

School Information Student ID Current Grade Level

How did you hear about PREP? Teacher☐ Counselor☐ Friend☐ Online☐ School Currently Attending

Type of School Public☐ Private☐ Charter☐ Homeschool☐

Other☐

Other☐ School District School Location: Urban☐ Rural☐ Sub-Urban☐

Parent/Guardian’s Consent (To Be Signed by Parent/Guardian AND Student) As the parent/guardian of the above named student, I certify that my child has my permission to participate in the PREP High School Academy at New Mexico State University. He/She is committing to attend PREP for the entire duration of the program. It is my understanding that he/she will be subject to ALL of the rules and regulations of the program.

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PREP High School Academy Student Essay A student-written essay must be included with this application. The student essay is to be typed or neatly hand written. The essay should be between 250-500 words, less than 3,250 characters. In your essay tell the selection committee why you are interested in attending the PREP High School Academy. Include in your essay what you hope to gain from this experience, how you think it will help you in the future and why you think you should be selected to attend this camp. Be sure to write your name, Student ID and current grade level at the top of your essay. Name: Grade:

Student ID:

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PREP High School Academy Teacher Recommendation Name of Teacher

Dear Teacher, The student who gave you this form is applying to attend the PREP High School Academy, a 2-week residential STEM program at New Mexico State University. Please complete the recommendation below. When you finish, put this form and recommendation into an envelope, seal it, and write your name across the sealed flap, so that your comments will be private. Please return the sealed envelope to the student or parent as soon as possible. The application deadline is March 31, 2016. Name of student_________________________________________________

Student ID_________________

Course taken with this teacher: Subject______________________________________

Year__________________

Please put an X in the appropriate column for each of the following statements: Very Much

Often

Sometimes

Rarely

Never

This student was eager to learn. This student cared about other students. This student was late to class. This student skipped classes. This student turned in homework and projects on time. This student participated in class, group and handson activities. This student worked independently and as a team member. This student was an asset to the class. This student participated in co-curricular activities (science fair, science club, etc.).

Do you recommend this student to the PREP High School Academy? Please include 2-3 sentences explaining why or why not.

School Name _________________________________________________________________ Teacher Signature ____________________________________

Date__________________

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PREP High School Academy Math or Science Teacher Recommendation Name of Teacher

Dear Teacher, The student who gave you this form is applying to attend the PREP High School Academy, a 2-week residential STEM program at New Mexico State University. Please complete the recommendation below. When you finish, put this form and recommendation into an envelope, seal it, and write your name across the sealed flap, so that your comments will be private. Please return the sealed envelope to the student or parent as soon as possible. The application deadline is March 31, 2016. Name of student_________________________________________________

Student ID_________________

Course taken with this teacher: Subject______________________________________

Year__________________

Please put an X in the appropriate column for each of the following statements: Very Much

Often

Sometimes

Rarely

Never

This student was eager to learn. This student cared about other students. This student was late to class. This student skipped classes. This student turned in homework and projects on time. This student participated in class, group and handson activities. This student worked independently and as a team member. This student was an asset to the class. This student participated in co-curricular activities (science fair, science club, etc.).

Do you recommend this student to the PREP High School Academy? Please include 2-3 sentences explaining why or why not.

School Name _________________________________________________________________ Teacher Signature ____________________________________

Date__________________ Page 11

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Form 3.4 LETTER TO PARENTS REGARDING SFSP SERVICES Dear Parent or Guardian: We are seeking assistance for food service under the Summer Food Service Program for Children (SFSP). This program is funded by the United States Department of Agriculture and administered by the New Mexico Children, Youth and Families Department. Our organization can receive reimbursements for meals served to children that meet SFSP eligibility criteria. Meals are available and will be provided free to all children, without regard to race, color, national origin, sex, age or disability. For purposes of SFSP reimbursement for meals served to children, free of charge, at Residential Camps, Day Camps, and ClosedEnrolled Sites:  An Income Eligibility Application (IEA) must be completed and must contain the SFSP participant’s name, names of all household members, current household income, a social security number of an adult household member or an indication that a household member does not possess one, and the signature of an adult household member. Participants with household incomes equal to or less than those indicated on the attached SFSP Income Eligibility Standards are eligible for free meals. Children who are part of households that receive food stamps, or benefits under the Food Distribution Program on Indian Reservations (FDPIR), or Temporary Assistance for Needy Families (TANF) are categorically (automatically) eligible to receive free meal benefits at eligible Program sites. Family size and income data for these children is not required when completing the IEA but a food stamp, FDPIR or TANF case number is. Please complete the attached SFSP Income Eligibility Application. This information will be maintained in strict confidence.

In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write to: USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 7205964 (voice and TDD). USDA is an equal opportunity provider and employer.

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Form 3.2

SUMMER FOOD SERVICE PROGRAM (SFSP) INCOME ELIGIBILITY APPLICATION PART 1. INDICATE NAMES AND AGES OF CHILDREN FOR WHOM THE APPLICATION IS MADE: NAME

AGE

NAME

AGE

_______ _______ _______

______ ______ ______

PART 2. HOUSEHOLDS NOW RECEIVING BENEFITS FOR FOOD STAMPS (SNAP), FOOD DISTRIBUTION PROGRAM ON INDIAN RESERVATIONS (FDPIR) OR TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF): COMPLETE THIS PART AND SIGN THE STATEMENT IN PART 4. DO NOT COMPLETE PART 3.

SNAP Case #:

FDPIR I.D. #: ____________ TANF Case #: ____________

PART 3. ALL OTHER HOUSEHOLD INFORMATION: IF YOU DID NOT COMPLETE PART 2, COMPLETE THIS PART AND PART 4. a.) Names of Household Members. List all related and unrelated persons who live in your household and share living expenses or meals. (Do not include children listed above.)

NAME _______________________ _______________________ _______________________

NAME ______________________ ______________________ ______________________

NAME _____________________ _____________________ _____________________

TOTAL NUMBER IN HOUSEHOLD: b.) Household Income - Total per month before taxes: Indicate the source and amount of current income for all members of your household. Follow the definition of income specified in the income eligibility standards. If you receive more than one check from any of these sources, indicate the total monthly amount received. Wages, Salary: $ Child Support/Alimony: $ TOTAL MONTHLY INCOME: Social Security: $ Pension/Retirement: $ Unemployment: $ Other Income: $ $_____________ PART 4. SIGNATURE AND PENALTIES FOR MISREPRESENTATION: I certify that the above information is true and correct and that the SNAP, FDPIR or TANF numbers are correct or that all income is reported. I understand that this application is being made with the receipt of Federal funds and that program officials may verify the information on this application. I further understand that deliberate misrepresentation of any of the information on this application may subject me to prosecution under applicable State and Federal Laws.

__

X X X - X X - ___ ___ ___ ___

Signature of Adult Family Member

Social Security Number

Households with incomes of less than or equal to the values indicated on the attached SFSP Income Eligibility Standards are eligible for free Program meals. If the child/children, for whom this application is being completed, is a member of a household that receives SNAP (Supplemental Nutrition Assistance Program), TANF (Temporary Assistance for Needy Families) or FDPIR (Food Distribution Program on Indian Reservations) benefits, they are automatically eligible to receive free meals in the Program. Foster children are categorically (automatically) eligible for free and reduced price meals regardless of household income. The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the social security number of the adult household member who signs the application. The social security number is not required when you apply on behalf of a foster child or when you list a SNAP, FDPIR or TANF case number for your child or other FDPIR identifier or when you indicate that the adult household member signing the applica tion does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the Program. We may share your information with Medicaid or the State Children’s Health Insurance Program (SCHIP), unless you tell us not to. The information, if disclosed, will be used to identify eligible children and seek to enroll them in Medicaid or SCHIP. In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or, (3) email: [email protected] This institution is an equal opportunity provider.

FOR SFSP SPONSOR USE ONLY Sponsoring Organization

Eligible

Ineligible

_____

______________

Official Signature

Date

Updated 1/15/15. L:\ECS Family Nutrition Bureau\Albuquerque FNB\SFSP-Summer Food\WEB Forms\Web Forms 2015\3.2 Income Eligibility Application.doc

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Form 3.3

SUMMER FOOD SERVICE PROGRAM INCOME ELIGIBILITY STANDARDS EFFECTIVE JULY 1, 2015 through JUNE 30, 2016 HOUSEHOLD SIZE

INCOME YEAR

MONTH

WEEK

1

$21,775

$1,815

$419

2

$29,471

$2,456

$567

3

$37,167

$3,098

$715

4

$44,863

$3,739

$863

5

$52,559

$4,380

$1,011

6

$60,255

$5,022

$1,159

7

$67,951

$5,663

$1,307

8

$75,647

$6,304

$1,455

For each additional family member

$7,696

$642

$148

NOTICES TO PARENTS/GUARDIANS 

Households with incomes of less than or equal to the above values are eligible for free Program meals.



If the child/children, for whom this application is being completed, is a member of a household that receives food stamp, TANF (Temporary Assistance for Needy Families) or FDPIR (Food Distribution Program on Indian Reservations) benefits, they are automatically eligible to receive free meals in the Program. Foster children are categorically (automatically) eligible for free meals regardless of household income.

 DEFINITIONS OF TERMS 

"Income" means income before deductions for income taxes, employee's social security taxes, insurance premiums, charitable contributions, and bonds, etc. It includes the following: (1) monetary compensation for services, including wages, salary, commissions, or fees; (2) net income from non-farm self-employment; (3) net income from farm self-employment; (4) social security; (5) dividends or interest on savings or bonds, income from estates or trusts or net rental income; (6) public assistance or welfare payments; (7) unemployment compensation; (8) government civilian employee, or military retirement, or pensions or veteran's payments; (9) private pensions or annuities; (10) alimony or child support payments; (11) regular contributions from persons not living in the household; (12) net royalties; (13) "Military benefits received in cash, such as, housing allowance for military households living off-base, food allowance, and uniform allowance, must be considered as income"; (14) and other cash income.



“Household” means "family" as defined in Section 7 CFR, Part 225.2. Family means in the case of children, a group of related or nonrelated individuals who are not residents of an institution or boarding house, but who are living as one economic unit. USDA is an equal opportunity provider. Updated 1/8/16. L:\ECS Family Nutrition Bureau\Albuquerque FNB\SFSP-Summer Food\WEB Forms\Web Forms 2016\3.3Income Eligibility Standards.doc

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SUMMER FOOD SERVICE PROGRAM

CIVIL RIGHTS STATEMENT IN ACCORDANCE WITH FEDERAL LAW AND U.S. DEPARTMENT OF AGRICULTURE POLICY, THIS INSTITUTION IS PROHIBITED FROM DISCRIMINATING ON THE BASIS OF RACE, COLOR, NATIONAL ORIGIN, SEX, AGE, OR DISABILITY. TO FILE A COMPLAINT OF DISCRIMINATION, WRITE USDA, DIRECTOR, OFFICE OF CIVIL RIGHTS, ROOM 326-W, WHITTEN BUILDING, 1400 INDEPENDENCE AVENUE, SW, WASHINGTON, D.C. 20250-9410 OR CALL (202) 720-5964 (VOICE AND TDD). USDA IS AN EQUAL OPPORTUNITY PROVIDER AND EMPLOYER. DE ACUERDO A LO ESTABLECIDO POR LAS LEYES FEDERALES Y EL DEPARTAMENTO DE AGRICULTURA DE LOS EE.UU. (USDA, SIGLAS EN INGLÉS), SE PROHIBE A ESTE ORGANISMO LA DISCRIMINACIÓN POR RAZA, COLOR, ORIGEN NACIONAL, SEXO, EDAD, O IMPEDIMENTOS DE LAS PERSONAS. PARA PRESENTAR UNA QUEJA SOBRE DISCRIMINACIÓN, ESCRIBA A USDA, DIRECTOR, OFFICE OF CIVIL RIGHTS, ROOM 326-W, WHITTEN BUILDING, 1400 INDEPENDENCE AVENUE, SW, WASHINGTON, D.C. 20250-9410, O LLAME AL (202) 720-5964 (VOZ Y TDD). USDA ES UN PROVEEDOR Y EMPLEADOR QUE OFRECE OPORTUNIDAD IGUAL A TODOS.

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PREP High School Academy Application Checklist Deadline to Apply

The deadline to submit your application is March 31, 2016. Include all application documents together in one packet and please DO NOT staple your application. Mailing Address: Tracey O’Neil-PREP College of Engineering New Mexico State University MSC 3449, P.O. Box 30001 Las Cruces, NM 88003

Delivery Address: Tracey O’Neil-PREP College of Engineering New Mexico State University Goddard Hall Rm. 310 1100 S. Horseshoe Las Cruces, NM 88003

Application Checklist Student Application Form Student Essay Two teacher recommendations, one must be from a Science or Math teacher. Income Eligibility Application Copy of current report card Copy of PARCC Scores (see below) Mathematics Score Report English Language Arts/Literacy Score Report

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NMSU PREP College of Engineering New Mexico State University MSC 3449, P.O. Box 30001 Las Cruces, NM 88003 (575) 646-2913 [email protected]

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