PARENTS AND STUDENTS DO YOU FEEL LIKE YOU NEED ADDITIONAL ACADEMIC SUPPORT? making a difference Operation Jump Start (OJS) is looking for students who are interested in going to college! We provide 6th -12th grade students with FREE resources which help them reach their academic goals. We partner them with a mentor who will work with the student for up to 5 years! BENEFITS OF THE PROGRAM ARE: through mentoring - College Scholarships - Free Tutoring - Fun Monthly Activities - Individualized Case Management -EVERYTHING IS FREE!!! AMONG OJS GRADUATES ... -100% graduate on time from high school - 80% of all graduates have either earned a Bachelors degree or are still persisting in school! Follow us on TWITTER @ OJS_mentoring or on FACEBOOK @ Opjumpstart for the latest info and events. Office #: 562.988.2131 Fax #:562.989.4661 Address: 3515 Linden Ave. Long Beach CA 90807 email: [email protected] or visit: www.operationjumpstart.org ! OPERATION JUMP START PROGRAMS ! COLLEGE&START& ! POSITIVE&FUTURES& MENTORING& ! COLLEGE&ACCESS& MENTORING& ! COLLEGE&SUCCESS& STUDENT REQUIREMENTS: STUDENT REQUIREMENTS: STUDENT REQUIREMENTS: STUDENT REQUIREMENTS: GRADE: 6th - 8th graders GRADE: Rising 7th - 10th graders GRADE: Rising 8th graders – 12th grade GPA: ANY GPA: 2.0 – 3.0 GPA: 3.0 or higher GRADE: (College Access Mentoring Graduates ONLY) 1st year at 4 year college or attending community college GPA: 3.0 Encouraged OTHER: NONE OTHER: Parents without college degree OTHER: Parents without college degree OTHER: Must be aspiring to full-time study QUICK SUMMARY: QUICK SUMMARY: QUICK SUMMARY: QUICK SUMMARY: School based 10-week curriculum at select locations. Career exploration, College terminology, goal setting skills, time management, effective decision making, academic planning, College options 12 month program Mentor Match (same gender) Serving the following zip codes: 90805, 90806, and 90813 1-5 year program Mentor Match (same gender) SAT/ACT Review and Exam, Career Development/Workshops, College Scholarship Assistance, College Tours, Cultural Workshops, Educational Workshops, Financial Aid Workshops, Leadership Development, Parent Workshops, Social Programs and Community Service Programs 12 month program for BA students Minimum 2 year program for community college students or until eligible for transfer to a university INCENTIVES: INCENTIVES: INCENTIVES: INCENTIVES: Fun Weekly Classes (Evidence Based Material – “Why Try”) Improvement of Problem Solving Skills and Self Esteem Building Academic Assistance Weekly Prizes * Eligible to enroll into Positive Futures Mentoring (PFM) or College Access Mentoring (CAM) if all requirements have been met Fun Monthly Events (i.e. mini golf, beach party) Problem Solving and Self Esteem Building courses Rewards For Academic and Social Improvement (i.e. $100 shopping spree, Free Computers, Free School Supplies) Academic Case Management * Eligible to enroll into College Access Mentoring (CAM) if all requirements have been met Fun Monthly Events (i.e. mini golf, beach party) OJS College Scholarship (for up to 5 years post graduation) Free Computer after your 1st year in the program Free School Supplies Annually Cash incentives for Academic Success (4.0 GPA) Academic Case Management Leadership Experience (YLC) OJS College Scholarship (for up to 5 years post graduation) Free School Supplies Annually Academic Case Management * Upon graduation, students are automatically enrolled into College Success ! ! Updated:!6/27/2013! 3515 Linden Avenue, Long Beach, CA 90807 Phone: 562-988-2131 ! Fax: 562.989.4661 ! Email: [email protected] 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 School Meal Program: Free Sibling Previously in program: 2 Parents Reduced Y Extended Family Foster Other: ____________________________ None 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 __Shy __Intelligent __Talkative __Outgoing __Friendly __Curious __Fun-loving __Confident __Moody __Cheerful __Stubborn __Sensitive __Spiritual __Thoughtful __ Practical __ Athletic __ Reserved __ Creative __ Emotional __ Ambitious Tennis Track Soccer Writing Electronics Boxing Jogging Bicycling Volleyball Wrestling Crafts Video Games Checkers Scuba Diving Surfing Board Games Exercising Outdoors Acting Repairing Cars Astronomy Please circle all activities below that interest you: Painting Reading Music Football Woodcarving Chess Bowling Computer Camping Movies Golf Sewing Billiards Fishing Basketball Hiking Swimming Martial Arts Collecting Museums Skating Politics Cooking Baseball Dancing Gardening Photography Hockey Other: ___________________________________________________________________________________________ Revised 11/12 3515 Linden Avenue, Long Beach, CA 90807 Phone: 562-988-2131 ! Fax: 562.989.4661 ! Email: [email protected] 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. Sincerely, _______________________ 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. Sincerely, _______________________ Parent/Guardian Signature ____________________________ Print Name _____________________ Date _______________________ Parent/Guardian Signature ____________________________ Print Name _____________________ Date Approved by: ______________________________ Revised 11/12 3515 Linden Avenue, Long Beach, CA 90807 Phone: 562-988-2131 ! Fax: 562.989.4661 ! Email: [email protected] PARENT/GUARDIAN INFORMATION Parent/Guardian 1: Full name: ____________________________________ Relationship to applicant: _______________________________ Employer: __________________________ Work phone: (___)_______________Cell phone: (___)__________________ E-mail: ________________________________ Did you graduate from high school? Did you graduate from college? Yes 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? Did you graduate from college? Yes 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 Has your child ever been involved with any legal systems? Yes College No If yes, please list:___________________________ 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: (___)__________________ Revised 11/12 Name3of3Student:____________________ On3the3following3income3chart,3please3put3a3check3on3the3box3that3applies3to3your3household.33 Income'Chart' Total3Home3Income3a3Year3 #3of3people3living3at3home3 $0#$10,000 $10,000#$20,000 $20,000#$30,000 $30,000#$40,000 $40,000#$50,000 $50,000#$60,000 $60,000#$70,000 $70,000#$80,000 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 8 8 8 8 8 8 8 8 8 *The3number3of3people3living3in3your3home3includes3everyone3under3your3roof.3It3may3include3grandparents,3 siblings,3friends3of3the3family,3and3anyone3else3that3is3living3with3you3for3any3reason3other3than3a3short3visit.3 Parent3Signature:____________________ Date:3____________ 3515 Linden Avenue, Long Beach, CA 90807 Phone: 562-988-2131 ! Fax: 562.989.4661 ! Email: [email protected] 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 SSN: _________________________________ Parent/Guardian Signature: _____________________________ _____________________________________ Designation and authorization accepted by OJS Representative ________________ Date Revised 11/12
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