Student Name Last First APPLICATION FOR ADMISSION Submit the following documents in order to complete application. All documents must be submitted for an application to be considered complete. Application must be complete before student will be considered for an interview. Use this checklist to be sure everything is turned in: Priority Deadline: January 15 to receive a decision by March 15. Completed Student Personal Information form Completed Student Information Insert - must be completed in student’s handwriting Completed Household and Financial Information form Signed “Request for Student Records” form so that Cristo Rey Jesuit can obtain final and most recent records from the applicant’s current school Three (3) Recommendation Forms Teacher Evaluation in Language Arts/English Teacher Evaluation in Math Counselor/Principal Evaluation Copy of student’s birth certificate or other proof of age. Student must be at least fourteen years old by Sept. 1 Copy of parents’ 2013 or 2014 1040 tax return, 2014 W-2 forms and paystubs. If you receive social assistance, please include copy of last statements. Copy of student IEP or other similar documentation (if applicable) Cristo Rey Jesuit College Preparatory School of Houston does not unlawfully discriminate on the basis of race, color, gender, sexual orientation, religion, national, or ethnic origin in its student admissions process, faculty and staff hiring practices, educational policies, scholarships, athletics, or other school administered programs. Cristo Rey Jesuit College Preparatory School of Houston 6700 Mount Carmel Street | Houston, TX 77087 Phone 281.501.1298 | Fax 281.501.3485 | cristoreyjesuit.org Student’s Personal Information (please write clearly) Application for: 9th 10th 11th Attach Student Photo Here Male Female 12th Full Name Last First MI Language spoken at home Phone Number Home Cell Student Cell Number Student E-Mail Birth Date Month Day Year Birthplace City State Country Ethnic Background *Optional (check all that apply) African American Hispanic/ Latino African Caucasian Asian Pacific Islander Native American Other School Information Current grade What school do you currently attend? City State How many years have you attended this school? Is your current school private or public? If public, list district: Religious Information (we welcome students of all faith traditions.) Religion, if any City Place of Worship State Cristo Rey Jesuit Connection How did you hear about Cristo Rey Jesuit? (circle) Mail Radio TV School Family Friend Church Other__________________ Do you have any siblings currently attending or applying to Cristo Rey Jesuit? Names & Grades of Siblings at Cristo Rey Jesuit: 2 HOUSEHOLD AND FINANCIAL INFORMATION Parents’ marital status Married Parent or Guardian 1 Information Divorced Separated Widow/Widower Single Parent Only include information of those living in the same household as the applicant. Name Relationship to applicant Year of Birth Phone Highest level of education completed Associates High School/GED Elementary Masters Bachelors Work Status Employed Unemployed Retired High School/GED Employer Self-Employed Associates 2013 Earnings Parent or Guardian 2 Information Homemaker Disabled Student 2014 Estimated Earnings Name Year of Birth Relationship to applicant Phone Highest level of education completed Elementary High School/GED Associ- Bachelors Masters Work Status Employed Employer Unemployed Retired Self Employed 2014 Earnings Homemaker Disabled Student 2015 Estimated Earnings PARENTS/ GUARDIANS: Please answer the following questions in the space provided: Explain your reasons for wanting your student to attend Cristo Rey Jesuit: At Cristo Rey Jesuit, your student will be provided a job that s/he must keep. What abilities does your student have that will help him/her to be successful as an employee in a workplace? 3 HOUSEHOLD INFORMATION Your household is expecting another child this year. You are in the process of a divorce or separation. A household member has been recently diagnosed as severely ill. A household member has a problem (addictions, mental illness, etc.) that is causing financial stress for the family. There has been a recent death in the household. A parent/guardian is widowed. Your household does not pay rent or mortgage. Your household does not file a 1040 tax document. A parent/guardian is a member of the military or clergy. STUDENT BACKGROUND Does the applicant suffer from any serious illness, physical or emotional limitation, depression, or other mental illness? Please explain: ________________________________________________________________________ ___________________________________________________________________________________________ Has the applicant ever been arrested or convicted of a crime? No Yes Has the applicant ever had a psycho-educational evaluation? Yes No Has the applicant ever been tested for, or diagnosed with, a learning disability? Yes No Has the applicant ever been tested for, or diagnosed with, ADD or ADHD? Yes No Has the applicant, now or ever, been enrolled in a special education class? Yes No Is the applicant now enrolled in an English as a Second Language Program (ESL)? Yes No Does the applicant currently have, or ever had, an Individual Education Plan? Yes No Copies of Evaluations and IEPs must be attached to this application. If answered YES to any of the questions above, please explain: _______________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ IMPORTANT NOTE TO PARENTS & GUARDIANS: Please review carefully and sign below. I understand Cristo Rey Jesuit College Preparatory School of Houston is a Catholic college preparatory school which combines personal responsibility, academic rigor, and a corporate work-study program to empower students of all faiths to reach their full potential. All students will adhere to a code of mandatory attendance, At Cristo Rey Jesuit High School, your student will be provided a job that s/he must keep. What skills or characteristics does dress and conduct. I further understand that full participation of parents and guardians is necessary in order to your student have that of willthe help him/her to be successful as an employee in a workplace? fulfill requirements program. Applicant’s Signature Date Parent/Guardian Signature Date Admission to Cristo Rey Jesuit College Preparatory School of Houston is contingent upon successful completion of the applicant’s current grade. I certify that information furnished in this application is complete and accurate. Furthermore, I understand that if I knowingly provide false information, I may jeopardize my child’s application. FAMILY EDUCATION RIGHTS AND PRIVACY ACT OF 1974 Under provisions of this act you have the right, if your son or daughter is enrolled at Cristo Rey Jesuit College Preparatory School of Houston, to review his or her educational records. The act further provides that you may waive your right to see recommendations for admission. I hereby acknowledge that I will be unable to review any recommendation forms for admission without the explicit consent of the recommender. Parent/Guardian Signature 4 Date STUDENT INFORMATION INSERT We know that you are more than your test scores and grades. Please use the questions on the front and back of this sheet as an opportunity to tell us more about yourself. Please answer the following questions in 3-5 complete sentences. The questions should be answered only in your own handwriting; no typed answers, please. What are your plans for the future and what keeps you focused on reaching these goals? How would a teacher describe you as a student in his/her class? Why do you want to attend Cristo Rey Jesuit College Preparatory School of Houston? 4 Our school has a longer school day, homework everyday, and five full days a month of work in an outside job. What skills and qualities do you have that will contribute to make you successful in our program? Please fill this box with something that you feel best represents you. Be creative!
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