Application - Middle College High School at Volunteer State

MCHS Application
Due March 20, 2015
Student Information
Student______________________________________________________________________________________
Last
Name First
Name M.I.
Address______________________________________________________________________________________
City _____________________________________________________State________________Zip_____________
Current Sumner County School __________________________________________Current Grade____10 th____11th
Age ______Date of Birth _____/_____/_____ Social Security # ____________________________Male ____ Female ____
Home phone ____________________________________ Cell Phone ___________________________________
E-mail Address ___________________________________________________________________________________
Parent(s)/Guardian(s)
Mother’s Name _______________________________________________Home Phone ____________________________
Cell Phone ___________________________________ Work Phone___________________________________
E-mail Address _________________________________________________________________________
Father’s Name _______________________________________________Home Phone ____________________________
Cell Phone ___________________________________ Work Phone___________________________________
E-mail Address _________________________________________________________________________
Academic Information
How many credits have you earned toward graduation? _________
What is your overall GPA? _____________ What was your last semester’s GPA?______________
Are you in good standing at your present high school? ______Please explain any unusual circumstances.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What is your current class schedule?
_____________________________
____________________________
_____________________________
____________________________
Do you have any ISS or OSS offenses and have you attended R. T. Fisher Alternative High School? Please
explain circumstances and provide dates. Please use the back if you need more room.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
If you are selected to attend Middle College High School, you will be responsible for your own transportation. How do you plan to get to and from Volunteer State? What is your backup plan?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Please answer the following questions:

Did either of your parents graduate from high school? Yes No

Is anyone in your immediate family serving or has served in the military?
Yes
No

Is any other language other than English spoken in your home?
Yes
No

Have you ever considered dropping out of school? Explain if yes.
Yes
No
College? Yes
No
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Do you feel a lack of belonging at your current school? Explain if yes. Yes
No
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Write an essay of at least 150 words stating why you want to attend Middle College High
School and how this will impact your future goals? Please attach your essay. This must be
typed and written by the student who is applying to MCHS.
Send your ACT scores to the address below as soon as you receive notification. Please send
a copy of the “View Your Scores” sheet from ACT with your name and ACT showing on the
page.
Attach a current transcript which you can obtain from your high school counselor, your
typed essay and the Parent/Student Agreement form to this application and take or mail
to : Middle College High School, Wood Campus Center, Suite217B, 1480 Nashville Pike, Gallatin, TN 37066.
DEADLINE March 20, 2015
Counselor ________________________________________ Sumner County Public High School _________________________
Student Name ______________________________________________ (Please Print) Date of Birth ___/___/___ M__F__
I have applied for admission to the Middle College High School program at Volunteer State and have been asked to provide a
counselor and principal reference.
Student’s Signature____________________________________________
Counselor,
all information will be kept confidential. Please complete the sections below and have your principal sign.
Please send to the Middle College High School by courier no later than March 20, 2015. You will be receiving teacher recommendations on this student also. Please sent those by courier to the Middle College High School at VSCC. Thank you for your
help.
How long have you known the applicant? ________________________
Please check the qualities that best describe the applicant:
______ bright/intelligent
______ capable of performing at a higher level
______ demonstrates strong artistic abilities
______ seeks academic challenges
______ desires more freedom or independence
______ participates in class discussions
______ shows leadership abilities
______ eager to join the “adult world”
______ consistent in academic effort
______ good conduct
______ organized time management
______ shows interest in learning
______ mature
______ responsible
______ works independently
______ punctual
Please evaluate the student’s current overall performance in each category:
Attendance (include tardies):
Classroom Attitude:
Class Work:
Discipline/Work Ethic
Potential success in college/ motivated, self starter
_____excellent
_____excellent
_____excellent
_____excellent
_____excellent
____ good
____ good
____ good
____ good
____ good
_____fair
_____fair
_____fair
_____fair
_____fair
____ poor
____ poor
____ poor
____ poor
____ poor
_____inconsistent
_____inconsistent
_____inconsistent
_____inconsistent
_____inconsistent
Counselor Signature ______________________________________________ Date____________________
Principal Signature _______________________________________________ Date ___________________
Please use the back of the sheet for additional comments.
Sumner County Public School_________________________________ Teacher Name _____________________________
Student Name _____________________________________________( Please Print) Date of Birth ___/___/___
M__ F__
I have applied for admission to the Middle College High School program at Volunteer State and have been asked to provide a teacher reference.
Student’s Signature____________________________________________
Teacher,
all information will be kept confidential. Please complete the sections below and return it to the high school
counselor’s office at your school before March 20, 2015. Do not return to the student.
How long have you known the applicant? ________________________
Please check the qualities that best describe the applicant:
______ bright/intelligent
______ capable of performing at a higher level
______ demonstrates strong artistic abilities
______ seeks academic challenges
______ desires more freedom or independence
______ participates in class discussions
______ shows leadership abilities
______ eager to join the “adult world”
______ consistent in academic effort
______ good conduct
______ organized time management
______ shows interest in learning
______ mature
______ responsible
______ works independently
______ punctual
Please evaluate the student’s current overall performance in each category:
Attendance (include tardies):
Classroom Attitude:
Class Work:
Discipline/Work Ethic
Potential success in college/ motivated, self starter
_____excellent
_____excellent
_____excellent
_____excellent
_____excellent
____ good
____ good
____ good
____ good
____ good
_____fair
_____fair
_____fair
_____fair
_____fair
____ poor
____ poor
____ poor
____ poor
____ poor
_____inconsistent
_____inconsistent
_____inconsistent
_____inconsistent
_____inconsistent
Teacher Signature ______________________________________________ Date____________________
Please use the back of the sheet for additional comments.
Middle College High School at VSCC
Parent/ Student Agreement
All students at Volunteer State Community College, including Sumner County Middle College students, have access to and can
participate in student organizations through Volunteer State Community College except those not approved by VSCC for
high school student such as intramurals.
Volunteer State has a diverse student population. SCMC students may be attending classes with other students ranging in
age from 16 to 80.
Parents should contact the SCMC office if they require academic information, as professors are prohibited from discussing
students’ information with anyone other than the student.
In the event that the student is unable to complete a course (drops, makes an F, or makes a second D) parents are responsible for the price of any books rented through or bought from Volunteer State Community College and the cost of maintenance fees (tuition) for the unsuccessful coursework.
Volunteer State has permission to release student grades through email to the Sumner County Department of Education.
Midterm grades will be given to parents at the halfway point of each semester.
If a student’s grade point average is below 2.0, the student will receive academic probation and the parent/guardian will be
required to meet with administration.
Final high school transcripts will be released to Volunteer State Admissions and Records.
The student has permission to use Counseling and Advisement services at Volunteer State.
Students/Parents will not be permitted to register/drop/add classes without advisement from Sumner County Middle College
counselor or principal.
Students must participate in a Volunteer State sponsored orientation prior to their first semester.
Students are expected to:
Be prepared for and attend all classes as scheduled;
Sign in daily at the SCMC office (Sumner County Attendance Policy); and
Exhibit appropriate behavior and attitude in class and on campus.
I have read the policies and procedures of Volunteer State and understand that by becoming a Sumner County Middle College
student at Volunteer State, I must abide by the high school’s and the college’s rules and regulations. As a dependent of my parents, I give Volunteer State permission to release any information regarding my grades, attendance, academic standing, disciplinary action, or any other aspect of my student life to my parents or legal guardian.
_______________________________________________________
____/_____/________
Student Signature
Date of Birth
______________
Date
I have read the policies and procedures above and understand that by allowing my child to participate in the Sumner County Middle College program at Volunteer State, I am responsible for following the policies.
_______________________________________________________
Parent/Guardian Signature
______________
Date