For ESC use only
District/Campus:
________________________
_
For ESC use only
QAD: ________________
2014 Washington Trip
Application
Late applications will NOT be accepted
SECTION I: Applicant Information – Print or type responses
1. Name:
___________________________________________________________________________________________
(Last name)
(First name)
2. Date of Birth:______/_______/_______
Month
Day
(Middle name)
3. ❑ Male ❑ Female
Year
4. Social Security Number: ________ - ________ - _________
5. Mailing Address: ___________________________________________________________________________
Number
Street Name
6. Home Phone: (____) __________________
Area Code
City
Zip Code
7. Cell Phone: (____) _______________________
Number
May we text-message you? ❑ Yes ❑ No
State
Area Code
Do you prefer to be contacted on ❑ Home Phone
Number
❑ Cell Phone
8. Email address: ___________________________________________________________
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 phone: (___) _______________________
Area Code
Number
Business phone:(___) ___________________________
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 who 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 violations? ❑ Yes* ❑ No
* If yes, please explain:
_____________________________________________________________________________________________________________________
SECTION III: School Information
15. Name of School/District: _____________________________________________________________________
16. Grade Level: ______
17. Mailing Address: ____________________________________________________________________________
number/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 (if applicable)
(Home building, etc.)
(Girl Scouts, Spanish Club, etc.)
Date of service/number of hrs
________________
__________________________________________
______________________
________________
__________________________________________
______________________
________________
_________________________________________
______________________
Awards and Honors
Name of Award
Organization granting award
Date received
_____________
_______________________________________
___________________
_____________
______________________________________
___________________
_____________ _
______________________________________
___________________
Employment/Internships/Summer Activities
Activity
Describe duties/activity
Hours per week
Dates (From/To)
____________
________________________________
____________
_______________
____________
________________________________
____________
_______________
____________
________________________________
____________
_______________
SECTION VI: Writing Demonstration
Please answer the following question or statement. We prefer a typed response but will accept a handwritten answer.
However, please make sure your handwriting is legible. Your response will play an important role in our evaluation
of your application. Please ensure your response is attached to the application.
Please respond to only ONE of the following by providing a well-written composition of at least 300 words:
Option 1.
Describe a setting in which you have collaborated or interacted with people whose experiences and /or beliefs differ
from yours. Address your initial feelings, and how those feelings were or were not changed by this experience.
Option2.
Describe a circumstance, obstacle or conflict in your life, and the skills and resources you used to resolve it. Did it
change you? If so, how?
Option 3.
Considering your lifetime goals, discuss how your current and future academic and extra-curricular activities might
help you achieve your goals.
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 ESC 20, Migrant Education 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 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 ESC 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_______________________________
Once complete, you may either mail or fax your application to:
Veronica Esparza
ESC 20
1314 Hines St.
San Antonio, TX 78208
Email: veronica.esparza@esc20.net
Fax:
210-370-5744