For ESC use only
District/Campus:
________________________
_
For ESC use only
QAD: ________________
2015 Washington Trip
Application
Late applications will NOT be accepted
SECTION I: Applicant Information – Print or type responses
1. Name:
___________________________________________________________________________________________
(Last name)
(First name)
3. ❑ Male ❑ Female
2. Date of Birth:______/_______/_______
Month
Day
(Middle name)
Year
4. Social Security Number: ________-________-_________
5. Mailing Address: ____________________________________________________________________
Number
Street Name
City
State
Zip Code
6. Telephone at mailing address: (_____) ____________ 7. Cell Phone: (_____) _______________________
Area Code
May we text-message you? ❑ Yes ❑ No
8. E-mail:
Number
Area Code
Do you prefer to be contacted on ❑ Home Phone
Number
❑ Cell Phone
______________________________________
_____________________________________________________________________________________________
SECTION II: Family Information
9. Father’s name: ______________________
Last First Middle
10. Mother’s name____________________________________
Last
First
Middle
Home address: __________________________
Number & Street City/ST/ Zip
Home address: __________________________________
Number & Street City/ST/Zip
Employer/Company: __________________
Employer/Company: __________________________
Job Title: ____________________________
Job Title: ____________________________________
Business Telephone: (___) _______________
Area Code
Number
Business Telephone :(___) _______________________
Area Code
Number
11. If not living with either parent, with whom do you live and what is their relationship to you?
_____________________________________________________________________________________________
12. List the names and ages of brothers and sisters:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
13. List any relative that has attended a Close-Up trip to Washington, DC and their relationship to you.
_____________________________________________________________________________________________
14. Have you ever been convicted of or do you currently have charges pending against you for breaking any laws
other than minor traffic offenses? ❑ Yes* ❑ No
* If yes, please explain:
_____________________________________________________________________________________________________________________
SECTION III: School Information
15. Name of School: __________________________________________________________________________
16. Your Grade Level: _________
17. Mailing Address:
_______________________________________________________________________________
Number and Street
City
State
Zip Code
18. Name of Counselor: ______________________________________
19. Phone Number: (________) ____________________
20. Counselors email address:_____________________________________________________________________
SECTION IV: Counselor Recommendation
21. How long have you known the applicant and in what capacity?________________________________________
22. This report is based on (Check all that apply):
 Personal observation and contact with student
 Other counselors’ observations
 Records
 Teacher Comments
 Other (specify): _________________________________________________________________________
23. What is students’ cumulative GPA? ______________________
24. GPA is:
 Weighted
 Un-weighted
25. Number of absences to date: ___________________________
When application is submitted we will contact your counselor to discuss grades, attendance and
discipline.
SECTION V: Activities Outside of Class
You may use this section to describe your extracurricular activities, or you may provide a resume.
Extracurricular Activities
Activity
Description
Years of Participation
(What the club does, leadership positions held, hours per week)
(Freshman, sophomore, etc.)
_____________________
_________________________________________
_______________________
_____________________
_________________________________________
_______________________
_____________________
_________________________________________
_______________________
Community or Volunteer Service (not court mandated)
Type of Service
Organization that arranged the service (if any)
(Home building, etc.)
(Girl Scouts, Spanish Club, etc.)
Date of service# of Hours
___________
__________________________________________
______________________
___________
__________________________________________
______________________
___________
_________________________________________
______________________
Name of Award
Organization granting award
Date received
_____________
_______________________________________
___________________
_____________
______________________________________
___________________
_____________ _
______________________________________
___________________
Awards and Honors
Employment/Internships/Summer Activities
Activity
Description of duties/description of activity
Hours per week
Dates (From/To)
____________
______________________________
____________
_______________
____________
______________________________
____________
_______________
____________
______________________________
____________
_______________
SECTION VI: Writing Demonstration
Please answer the following question. Your answer will play an important role in our evaluation of your file. You
are welcome to attach your response to the application.
Please tell us in a well-written composition of at least 300 words:
Think of an issue of importance to you- the issue could be personal, school related, local, political, or
international in scope- and write an essay in which you explain the significance of that issue to yourself,
your family, your community, or your generation.
Note: If you have unique circumstances for the admission committee to consider, include a personal statement
detailing your situation, in addition to other relevant supporting documents.
Section VII: Good Conduct Rule
To retain eligibility for participation in the Close Up Leadership Academy, students must conduct themselves as
good citizens both in and out of school at all times. This policy is in effect and applied to student conduct 365 days a
year for students selected to participate in the Close Up Academy. Students who represent the school in an activity
are expected to serve as good role models to other students and to the members of the community.
A student may lose eligibility under the Good Conduct Rule for any of the following behaviors:

possession, use or purchase of tobacco products, regardless of the student’s age;

possession, use, or purchase of alcoholic beverages, including beer and wine ("use" includes having the
odor of alcohol on one’s breath);

possession, use or purchase of illegal drugs or the unauthorized possession, use or purchase of otherwise
lawful drugs;

engaging in any act that would be grounds for arrest or citation in the criminal or juvenile court system,
excluding minor traffic offenses, regardless of whether the student was cited, arrested, convicted, or
adjudicated for the act(s);

inappropriate or offensive conduct that constitutes a violation of the school’s code of conduct resulting in in
school suspension, home suspension, alternative school placement, or expulsion.
SECTION VIII: Signatures

I understand that if I am determined to be eligible and am offered the opportunity to attend the Close -Up
DC trip, the Region 20 Migrant Program will provide the financial resources required. I understand if I
am selected I must fully participate in all events, meetings and workshops that Region 20 requires us
to attend prior to the trip. All paper work must be submitted in a timely manner. If my child and I do
not comply with requests made by Region 20, my child will not be able to attend the DC trip. I certify
that the information provided in this application is true and correct.
Parent Signature: ___________________________________ Date:______________________________
Student Signature: __________________________________Date_______________________________
Mail to: Larry Rodriguez, 1314 Hines St., San Antonio, TX 78208 or Fax: 210-370-5744