Application for Admission
MI CASA Program
601 South College Rd.
Wilmington, NC 28403
Phone: (910) 962-2631 Fax: (910) 962-2543
PART A: To be completed by APPICANT
( ) Application
( ) Mentee Contract
( ) Create Sealevel account
( ) Short Answer
( ) Student Essay
PART B: To be completed by PARENT/GUARDIAN
( ) Parent/Guardian Information
( ) Parent/Guardian Demographics
( ) Parent/ Guardian Short answer
PART C: Reference Forms to be completed by CORE TEACHER
( )English Teacher
( ) Math Teacher
( ) Teacher of your choice
PART D: Educations Records Form to be completed by PARENT and COUNSELOR.
( ) Educational Records Access Request Form
( ) Current Transcript
( ) Attendance Profile
( ) Discipline profile
Student Name: _________________________________
School: ____________________
PART A: To be completed by APPICANT.
STUDENT INFORMATION
Nomination Criteria
 Must be a rising 11th grade Hispanic Student.
 Must have demonstrated on-going commitment to attending a post-secondary
school.
 Must have satisfactory academic transcripts, discipline records and course
selections.
 Must be U.S. citizen or Legal Permanent Resident.
Applicant Information
Student Name ________________________________________________________________________________
(Last)
(First)
(Middle)
School Name __________________________________________________________________________________
Date of Birth
___________________________
Student e-mail
___________________________
Student Cell # _______________________
Parents Place of birth ___________________________
___________________________
Student’s Nationality ______________________________
Create SeaLevel Account
www.uncw.edu/admissions/sealevel.htlm
SeaLevel Username ___________________________
Status
( ) U.S. Citizen
( ) U.S. Resident
( ) DACA
( ) Undocumented
Academic and Information
Hobbies (Sports, art, music, travelling, etc.)
_________________________________
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_________________________________
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List all your recent accomplishment/awards (academics, community or athletics)
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Please tell us about any extracurricular activities (community, church, Sports)
______________________________
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UNCW MI CASA Mentee Contract
Background: MI CASA (Mentors Initiating Community Actions, Support, and Advocacy)
mentoring program is designed to expand the educational opportunities for
Hispanic/Latino students in Pender, Brunswick and New Hanover County High School. My
CASA is a comprehensive support program that provides mentoring, college prep, tutoring,
community service projects, and cultural enrichment opportunities. There components
help prepare participants to become compelling candidates for college admissions.
As a mentee, we have the following expectations of you:





Attend all MI CASA events;
Transportation problems will not cause me to miss events: Contact both Program
Coordinator and your UNCW mentor 24 hours prior to the event if transportation is
a problem.
Contact with your mentor weekly via e-mail, phone, or social media.
Work with my mentor and complete all assignments. Ask for help to your mentor
or Program Coordinator.
Plan class schedules with input from your UNCW mentor and Program Coordinator.
In addition to the above, in your senior year you will also:
 Research and apply for admission to at least three colleges and universities
including UNCW.
 Research and apply to five scholarships.
Admission application to UNC Wilmington is a REQUIREMENT.
MI CASA cannot guarantee UNCW admission or college funding for every student. We will
provide all possible resources to ensure that every student who completes our program is
able to achieve a college education.
Applicant Signature ____________________________________
Date __________________
Short Answer
1.
What are your career goals?
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2.
How do you think MI CASA will help you?
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3.
What is your greatest strength?
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4.
How would your teachers describe you as a student?
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5.
Have you had behavior or disciplinary problems at school or have you ever been suspended?
If yes, explain.
__________________________________________________________________________________________
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____________________________________________________________________________ ______________
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Student Essay:
Please write an essay describing your reasons for going to college and why you should be
selected to this program. Include ways in which you will contribute to the UNCW Seahawk
Family during your two years with us.
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PART B: To be completed by PARENT/GUARDIAN
Parent/Guardian Information
Parent/Guardian Name ______________________________________________________________
(Last)
(First)
(Middle)
Address ___________________________________________________________________________
(St#)
(Street)
___________________________________________________________________________________
(City)
(County)
(State)
(ZIP)
Phone numbers
Mother __________________
(Home)
Father ___________________
(Home)
Guardian_________________
(Home)
Parent/Guardian E-mail address
Academics
Complete as
Applicable
_____________________
(Cell)
_____________________
(Cell)
_____________________
(Cell)
_____________________
(Work)
_____________________
(Work)
_____________________
(Work)
_____________________________________________________
Not a High
School Graduate
GED or HS
Equivalency
High School
Graduate
Number
Years
College
Degree
Held
Father/Step/Guardian
Mother/Step/Guardian
Household size (number of people living in home)
Please check accordingly:
Please check the appropriate family income
Estimated anual
less than
less than
family income
$25.000
$35.000
2
less than
$45.000
Evaluate your child on the following characteristics
Characteristics
Rarely
1
Motivated to achieve at school
Accepts responsibilities for learning
Work well with peers and siblings
3-4
5-6
less than
$55.000
- +
2
less than
$65.000
Occasionally
3
7-8
9+
more than
+75.000
-+
4
Mostly
5
Accepts responsibilities for his/her own actions
Makes mature and responsible decisions
Shows respects for others
Has problems with authority
Please Read Carefully
By submitting this application it is understood and agreed upon that:
 Any student attendance or behavioral problems will be sufficient cause to rescind admission to
MI CASA Program
Parent Signature ________________________________
Date ______________________
Why do you want your child to participate in the MI CASA Mentoring Program?
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How will you support your child as a participant of the MI CASA Program?
___________________________________________________________________________________________
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PART C: UNCW MI CASA Mentoring Program. Reference Form to be completed by
current of former ENGLIGH TEACHER. Please email this form to monteroc@uncw.edu by
May 1st. Email Subject: MI CASA RECOMMENDATION
The MI CASA (Mentors Initiating Community Action, Support, and Advocacy) mentoring program at the
University of North Carolina Wilmington is designed to provide access to higher education to
Hispanic/Latino high school students in North Carolina.
Student Name _________________________________________________________
Least
→ →
to
→ →
Highest
Academics
Academic potential
Academic preparation
Academic ambition/aspirations
Academically responsible and reliable
Study skills/ habits
Quality of academic work
Maturity for the college environment
Mature behavior
Responsible behavior
Confidence
Peer relations
Respect for other’s study needs
Respect for campus grounds and rules
Initiative to work independently
Class attendance, promptness to class
Achievement attitude
Academically responsible/reliable
Works without accommodations/assistance
Prompt completion of assignments
Teacher relations
Based on my experience with the applicant, I make the following recommendation:
( ) Highly Recommend
( ) Recommend
( ) Recommend with reservation
Name :______________________________________________
(please print)
Signature:___________________________________________
( ) Not Recommend
Position:_____________________________
(please print)
Date:_________________________________
Comments:
___________________________________________________________________________________________
___________________________________________________________________________________________
PART C: UNCW MI CASA Mentoring Program. Reference Form to be completed by
current or former MATH TEACHER. Please email this form to monteroc@uncw.edu by
May 1st. Email Subject: MI CASA RECOMMENDATION
The MI CASA (Mentors Initiating Community Action, Support, and Advocacy) mentoring program at the
University of North Carolina Wilmington is designed to provide access to higher education to
Hispanic/Latino high school students in North Carolina.
Student Name _________________________________________________________
Least
→ →
to
→ →
Highest
Academics
Academic potential
Academic preparation
Academic ambition/aspirations
Academically responsible and reliable
Study skills/ habits
Quality of academic work
Maturity for the college environment
Mature behavior
Responsible behavior
Confidence
Peer relations
Respect for other’s study needs
Respect for campus grounds and rules
Initiative to work independently
Class attendance, promptness to class
Achievement attitude
Academically responsible/reliable
Works without accommodations/assistance
Prompt completion of assignments
Teacher relations
Based on my experience with the applicant, I make the following recommendation:
( ) Highly Recommend
( ) Recommend
( ) Recommend with reservation
Name :______________________________________________
(please print)
Signature:___________________________________________
( ) Not Recommend
Position:_____________________________
(please print)
Date:_________________________________
Comments:
___________________________________________________________________________________________
___________________________________________________________________________________________
PART C: UNCW MI CASA Mentoring Program. Reference Form to be completed by
student’s TEACHER OF CHOICE. Please email this form to monteroc@uncw.edu by May 1st.
Email Subject: MI CASA RECOMMENDATION
The MI CASA (Mentors Initiating Community Action, Support, and Advocacy) mentoring program at the
University of North Carolina Wilmington is designed to provide access to higher education to
Hispanic/Latino high school students in North Carolina.
Student Name _________________________________________________________
Least
→ →
to
→ →
Highest
Academics
Academic potential
Academic preparation
Academic ambition/aspirations
Academically responsible and reliable
Study skills/ habits
Quality of academic work
Maturity for the college environment
Mature behavior
Responsible behavior
Confidence
Peer relations
Respect for other’s study needs
Respect for campus grounds and rules
Initiative to work independently
Class attendance, promptness to class
Achievement attitude
Academically responsible/reliable
Works without accommodations/assistance
Prompt completion of assignments
Teacher relations
Based on my experience with the applicant, I make the following recommendation:
( ) Highly Recommend
( ) Recommend
( ) Recommend with reservation
Name :______________________________________________
(please print)
Signature:___________________________________________
( ) Not Recommend
Position:_____________________________
(please print)
Date:_________________________________
Comments:
___________________________________________________________________________________________
___________________________________________________________________________________________
PART D: Educational Records Access Request Form and Counselor’s Recommendation.
TO BE COMPLETED BY PARENT: Educational Records Access Request Form The UNCW MI
CASA Mentoring Program strives to provide valuable assistance to students in regard to
gaining college access. Review of school records is essential in the pre-college mentoring
and planning process.
I hereby grant full access to my child’s academic records to UNCW MI CASA Program
Coordinator.
Student Name:
____________________________________________________________
Parent Name: __________________________________ Parent Signature: _________________________________
TO BE COMPLETED BY COUNSELOR:
Grades
Please email a copy of the applicant’s most recent transcript to monteroc@uncw.edu
Attendance
Total Absences for the current year_________________
Disciplinary Actions
Has the applicant had disciplinary infractions during high school?
If yes, please comment on the frequency and reasons.
( )Yes ( ) No
____________________________________________________________________________
____________________________________________________________________________
Based on my experience with the applicant, I make the following recommendation:
( ) Highly Recommend
( ) Recommend
( ) Recommend with reservation
Name :______________________________________________
(please print)
Signature:___________________________________________
( ) Not Recommend
Position:_____________________________
(please print)
Date:_________________________________
Comments:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________