Loudoun County Public Schools
Department of Pupil Services
21000 Education Court
Ashburn, Virginia 20148
Telephone: 571-252-1017
FAX: 571-252-1245
CAMPUS Application Packet for Upper Class Students
(2016 -2017)
CAMPUS invites interested upperclassmen to apply. CAMPUS, a School Counseling Services initiative
of Loudoun County Public Schools, is an academic and college preparation program beginning its
eleventh year in the 2016-2017 school year. CAMPUS is designed to meet the specific needs of students
from historically underrepresented groups in higher education and prospective first-generation college
students.
CAMPUS provides students with systematic and coordinated experiences to enhance academic success
and college preparation. The program supports students through critical experiences that begin from the
time students leave middle school until high school graduation. CAMPUS provides academic enrichment
and support, self-advocacy skills development, college and university visits, college and scholarship
preparation, leadership development, carefully guided course selection, community service opportunities,
and meaningful co-curricular and extracurricular activities. Selected students will be expected to enroll
in the CAMPUS class and/or attend mandatory meetings and participate in CAMPUS events and
activities throughout their high school years.
Candidates should show promise for high school and college success and will be selected based on a
variety of factors including:
 Potential aptitude for success in post-secondary education
 Leadership potential
 Demonstrated interest in learning
 Teacher recommendations
Strong consideration will be given to those students who:
 Will be first in their family to graduate from a college or university
 Come from a historically underrepresented group in higher education
 Come from a single parent family
 May be considered socioeconomically disadvantaged
If you are interested in applying, please submit the enclosed application form along with two teacher
recommendations to your school counselor. All applications received will be reviewed by a selection
committee, and students will be notified. If you have any questions, please contact Chris Clarke,
CAMPUS Program Manager, at 571-252-1017.
CAMPUS Application for Upper Class Students (2016-2017)
Please complete the application by printing clearly in ink or by typing. Additional pages may be attached. Please make sure
your full name is written or typed on each page. All information is confidential and will only be shared with counselors and
the selection committee. Please submit this application to your school counselor.
Name:
First
Middle Initial
Last
Preferred Nickname
Middle School:
High School:
Current Grade Level:
Home Address:
City:
Phone:
State:
Email:
Zip:
Date of Birth:
Student ID:
Optional: With
which ethnic gro
African American
Hispanic
Family Information
Information on adults with whom you reside:
Circle: Father/Stepfather/Guardian:
Circle: Mother/Stepmother/Guardian:
Name:
Name:
Occupation:
Occupation:
Employer:
Employer:
Email:
Email:
Highest Level of Education: (USA or Abroad)
years in high school
chool diploma
Highest Level of Education: (USA or Abroad)
years in high school
chool diploma
-Yr. college diploma (AA)
-Yr. college diploma (BS/BA)
Degrees beyond BS/BA or
Certifications
(School Attended)
-Yr. college diploma (AA)
-Yr. college diploma (BS/BA)
Degrees beyond BS/BA or
Certifications
(School Attended)
Optional:
Is your child eligible for free or reduced school lunch?
Yes
Does your family receive public assistance?
Yes
No
Does your family reside in federally subsidized housing?
Yes
No
No
Please list any languages other than English spoken at home:
Student’s Name:
Student Personal Responses
Please provide thorough answers to the following questions in the space provided on this sheet. Your
responses are an important part of the application and will be reviewed by the Selection Committee.
1. List your activities in your community and school and why they are important to you. Examples
can include activities in church, your community, youth groups, and your school. You may also
include responsibilities for helping others in your neighborhood, your family, and your school.
Also, list any leadership positions you have held.
2. Describe a special challenge you have had and how you overcame it.
3. What are your goals after high school graduation?
4. Why is it important for you to be a part of CAMPUS?
Student’s Name:
Student Checklist
I have completed all sections of the CAMPUS application.
I have answered the Student Personal Responses.
I have included two completed teacher recommendation forms.
I have discussed CAMPUS with my parent/guardian(s) and obtained their signature.
I understand that if I am selected as a CAMPUS 9th grader I will be expected to enroll in the CAMPUS
class and/or CAMPUS meeting at my high school and participate in all mandatory CAMPUS events. I
understand and I am willing to make this commitment.
Student Signature
Date
Parent/Guardian Section
Your son or daughter is applying to participate in CAMPUS, a Loudoun County Public Schools School
Counseling program designed to enhance academic and college preparation. Any questions about the
program may be directed to Chris Clarke, CAMPUS Program Manager, for Loudoun County Public
Schools. Parent/Guardian support and involvement are critical to the success of your child and the
program.
Please feel free to use the space below to provide the selection committee with information about your
child’s unique characteristics that make him/her a good candidate for CAMPUS.
Your signature below indicates that you are supportive of your child’s application and participation in
CAMPUS if selected. You also agree to participate in CAMPUS parent/guardian involvement activities
and events.
Parent/Guardian Signature
Date
Parent Comments:
Student’s Name
Teacher Recommendation for CAMPUS #1
Student’s Name:
Student’s Counselor:
Teacher’s Name:
Subject you teach the applicant:
Please return this form to your school counselor.
The student named above is applying to participate in CAMPUS, a Loudoun County Public Schools School
Counseling Services initiative. CAMPUS will provide students with systematic and coordinated experiences to
enhance academic and college preparation. CAMPUS is designed to meet the specific needs of students from
underrepresented populations in higher education and prospective first-generation college students.
The program seeks to identify students who have the ability to succeed academically in high school and college.
Students should read on or above grade level. Some of the students may be role models while others may need
support and nurturing. Students should demonstrate respectful behavior toward peers and staff members.
Your responses to the questions below will be added to the student application and will be reviewed by the
selection committee.
Please place a check in the appropriate box below to rate the student from 1-5 on the following:
1
Among top 5% of
students I’ve taught
2
outstanding
3
good
4
fair
5
weak
1. Academic potential,
“spark”
2. Desire to learn
3. Desire to excel
4. Citizenship
5. Leadership potential
6. Relationships with
peers
7. Relationships with
adults
8. Seeks help when
needed
Please attach a statement commenting on this student’s strengths and weakness, as well as any situations
in which the student has thrived as a result of positive adult attention, assistance, and/or reinforcement.
Feel free to provide any other information that might be helpful for the selection committee to know.
Thank you for your support and assistance.
Student’s Name:
Teacher Recommendation for CAMPUS #2
Student’s Name:
Student’s Counselor:
Teacher’s Name:
Subject you teach the applicant:
Please return this form to your school counselor.
The student named above is applying to participate in CAMPUS, a Loudoun County Public Schools School
Counseling Services initiative. CAMPUS will provide students with systematic and coordinated experiences to
enhance academic and college preparation. CAMPUS is designed to meet the specific needs of students from
underrepresented populations in higher education and prospective first-generation college students.
The program seeks to identify students who have the ability to succeed academically in high school and college.
Students should read on or above grade level. Some of the students may be role models while others may need
support and nurturing. Students should demonstrate respectful behavior toward peers and staff members.
Your responses to the questions below will be added to the student application and will be reviewed by the
selection committee.
Please place a check in the appropriate box below to rate the student from 1-5 on the following:
1
Among top 5% of
students I’ve taught
2
outstanding
3
good
4
fair
5
weak
1. Academic Potential,
“Spark”
2. Desire to learn
3. Desire to excel
4. Citizenship
5. Leadership potential
6. Relationships with
peers
7. Relationships with
adults
8. Seeks help when
needed
Please attach a statement commenting on this student’s strengths and weakness, as well any situations
where the student has thrived with positive adult attention, assistance, and/or reinforcement. Feel free to
provide any other information that might be helpful for the selection committee to know.
Thank you for your support and assistance.
Student’s Name:
CAMPUS Student
Contact Information Form
2016/2017
Student first & last name:
Student cell phone number:
Student primary email address:
Name of Father/Stepfather/Guardian:
Name of Mother/Stepmother/Guardian:
Father/Stepfather/Guardian cell phone
number:
Mother/Stepmother/Guardian cell phone
number:
Father/Stepfather/Guardian email address:
Mother/Stepmother/Guardian email address:
Home phone number:
Note: This page must be TYPED. This page will be kept strictly confidential.