Turning READY TO GET STARTED? APPLY TODAY!

Turning
How do we turn dreams into reality?
Glad you asked.
WHAT WE DO FOR STUDENTS . . .
3515 Linden Avenue | Long Beach 90807
For Long Beach students with potential but
limited support – Operation Jump Start
(nonprofit, 501c3) provides FREE academic
support services and mentoring - preparing
students to reach their academic goals and
dreams. Students: do you have a 3.0 GPA
or better? Are you the first person in your
family who will attend college? If so, you’re
eligible for admission, so apply TODAY!
WHY WE DO IT . . .
BENEFITS FOR OJS SCHOLARS…
We here at OJS believe everyone – regardless of
socio-economic status – deserve the resources
and support needed to succeed. We offer a guiding
hand to those with BIG dreams and goals!
Mentoring: OJS Students receive one-onone extensive mentoring for a minimum of 5
years. This makes OJS truly unique!
HOW WE DO IT . . .
Our programming offers each OJS student,
referred to as scholars, an incredible 5+ years of
extensive and involved support. Our scholars get a
super-charged team of mentors, tutors, and
counselors – all rich with the resources they need
to graduate high school, get into college, and get a
‘jumpstart’ in the right direction.
Academic Advising and Tutoring: Dedicated
program managers and tutors assist students
as they prepare for college admission
Scholarships:
OJS
Students
earn
scholarships to use towards eventual college
tuition and related academic expenses.
Enrichment Activities: Fun and free events
include social outings such as rock-climbing
and horseback riding, intensive college
readiness coursework e.g. SAT prep., college
tours, cultural events and so much MORE!
READY TO GET STARTED? APPLY TODAY! 3515 Linden Ave Long Beach CA 90807
562-988-2131 Main | 562-989-4661 Fax
STUDENT APPLICATION
All applicants must present the following with their application:
• Proof of U.S. residency or citizenship (Birth Certificate)
• Most current report card
Date ______________________
Student’s Full Name: ________________________________________________________________________________
Home Address: __________________________________________City: _____________________ State:____________
Zip Code :_________ Student ID Number: _________________________ Student’s Current Grade Level: ____________
Birth date: _____________________________ Gender: ❑M
❑F
Ethnicity: __________________________________
Language(s) spoken at home: __________________________ Student’s cell phone: (____)________________________
Student’s Email:_______________________________ Student’s home phone:(____)_____________________________
Residence Status: ❑ Single parent ❑ 2 Parents ❑ Extended Family ❑ Foster ❑ Other: ___________________________
School Meal Program: ❑ Free ❑ Reduced ❑ None
Sibling Previously in program: ❑Y
Student’s Social Security Number: _________________________
❑N If yes, what is their name:____________________________________________
Academics
School: _______________________ Counselor: ______________________ Counselor phone: (____)_______________
GPA: _________________ Absences (last semester/quarter): _________________________
Have you ever received a “D” or “F”? ❑Yes
❑No If yes, which class? ______________________________________
Clubs, hobbies, activities (on or off campus), sports teams, etc.:_______________________________________________
_________________________________________________________________________________________________
Possible career goal(s): ______________________________________________________________________________
Personality
I would describe myself as (check any that apply to you)
__Quiet
__Talkative
__Curious
__Moody
__Shy
__Outgoing
__Fun-loving __Cheerful
__Intelligent
__Friendly
__Confident
__Stubborn
Please circle all activities below that interest you:
__Sensitive
__Spiritual
__Thoughtful
__ Practical
__ Athletic
__ Reserved
__ Creative
__ Emotional
__ Ambitious
Painting
Computer
Basketball
Politics
Tennis
Bicycling
Surfing
Reading
Camping
Hiking
Cooking
Track
Volleyball
Board Games
Music
Movies
Swimming
Baseball
Soccer
Wrestling
Exercising
Football
Golf
Martial Arts
Dancing
Writing
Crafts
Outdoors
Woodcarving Sewing
Collecting
Gardening
Electronics
Video Games Acting
Chess
Billiards
Museums
Photography
Boxing
Checkers
Repairing Cars
Bowling
Fishing
Skating
Hockey
Jogging
Scuba Diving Astronomy
Other: ___________________________________________________________________________________________
What do you usually do on Saturdays? __________________________________________________________________
On a scale from 1 to 10, how sure are you that you want to attend college (10 being very sure):
_
1_
2_
3_
4_
5_
6_
7_
8_
9_
10
Why would you want to go to college: __________________________________________________________________
_________________________________________________________________________________________________
What factors do you think would stop you from going to college: ______________________________________________
_________________________________________________________________________________________________
Please tell us what having a mentor means to you: _________________________________________________________
_________________________________________________________________________________________________
Please give us a reason why you want to be in this program: ______________________________________________
_________________________________________________________________________________________________
If you accepted into the program, what type of workshops, events, or experiences would you like to participate in:_______
_________________________________________________________________________________________________
Is there anything else you want us to be aware of or want us to know about you: ________________________________
_________________________________________________________________________________________________
-------------------------------------------------------------------------STUDENT CONSENT FORM
I have read and understand and support the goals of Operation Jump Start. As a Scholar, I look forward to being matched with
a person who will be an adult friend and who will be my Mentor until I finish high school. I agree to follow all written rules and
abide by all program obligations as presented.
_______________________
Student Signature
_____________________________
Print name
______________________
Date
PARENT/GUARDIAN CONSENT FORM
I/we have read and do understand and support the goals of Operation Jump Start. I/we believe that my/our daughter/son,
_____________________________ will benefit from being an Operation Jump Start Scholar. I/we understand that as a
Scholar, my/our daughter/son will be matched with a Mentor and participate in the Mentor Program. I/we understand the role of
the Mentor and will support the relationship between my/our child and his/her Mentor. I will ensure that my child follows all of the
written rules and obligations as presented.
_______________________
Parent/Guardian Signature
____________________________
Print Name
_____________________
Date
_______________________
Parent/Guardian Signature
____________________________
Print Name
_____________________
Date
Approved by: ______________________________
PARENT/GUARDIAN INFORMATION
Parent/Guardian 1:
Full name: ____________________________________ Relationship to applicant: _______________________________
Employer: __________________________ Work phone: (___)_______________Cell phone: (___)__________________
E-mail: ________________________________ Did you graduate from high school? ❑Yes
Did you graduate from college? ❑Yes
❑No
❑No If yes, what level of college did you complete:_________________________
Which language are you most comfortable speaking: ____________________________
Parent/Guardian 2:
Full name: ____________________________________ Relationship to applicant: _______________________________
Employer: __________________________ Work phone: (___)_______________Cell phone: (___)__________________
E-mail: ________________________________ Did you graduate from high school? ❑Yes
Did you graduate from college? ❑Yes
❑No
❑No If yes, what level of college did you complete:_________________________
Which language are you most comfortable speaking: ____________________________
List the names, ages, and the schools of all the children in your household:
Name
Age
High School
Do you currently have health insurance for your child? ❑Yes
College
❑No If yes, please list:___________________________
Has your child ever been involved with any legal systems? ❑Yes
❑No If yes, please describe below:
_________________________________________________________________________________________________
Please give us the contact information of 2 people that we will be able to reach if you are unavailable:
Alternate Contact 1:
Full name: ____________________________________ Relationship to applicant: _______________________________
Address: _____________________________________ City: ______________ State:_______ Zip Code:______________
Home Phone: (___)___________________ Work phone: (___)_______________Cell phone: (___)__________________
Alternate Contact 2:
Full name: ____________________________________ Relationship to applicant: _______________________________
Address: _____________________________________ City: ______________ State:_______ Zip Code:______________
Home Phone: (___)___________________ Work phone: (___)_______________Cell phone: (___)__________________
To Principal/Custodian of Student Records:
I am ______________________________the parent of _______________________________, a pupil currently
enrolled at this school. Pursuant to the Family Educational Rights and Privacy Act ("FERPA"), California Education
Code, section 49069, and California Family Code, section 3025, I hereby request access to any and all pupil records
relating to my student maintained by the district and the school.
I hereby designate and authorize Operation Jump Start and ______________________________, a mentor from
Operation Jump Start, to act as my agents in this regard and grant them full and complete access to all such pupil
records, including but not limited to grades, attendance and other records regarding my pupil’s school information,
and any online data bases such as “School Loop.”
This request for access and authorization shall be continuous and ongoing and shall continue for the duration of my
pupil’s enrollment unless sooner revoked by me in writing.
Thank you for your anticipated prompt compliance with this request.
Student Name: _________________________________
Student School ID Number: _____________________ Student Social Security Number: __________________
Parent/Guardian Signature: _____________________________________
_____________________________________
Designation and authorization accepted by
OJS Representative
____________
Date