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 Rising 9th Grade Students
(2013 -2014)
CAMPUS invites interested students in the rising ninth grade to apply. CAMPUS, a Guidance Services
initiative of Loudoun County Public Schools, is an academic and college preparation program beginning
its eleventh year in the 2013-2014 school year. CAMPUS is designed to meet the specific needs of
students from historically under-represented 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 beginning in the 9th grade 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 an historically under-represented group in higher education
 Come from a single parent family
 May be considered socio-economically 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 Rising 9th Grade Students (2013-2014)
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 no later than March 15, 2013.
First Name:
Middle Initial:
Last Name:
Preferred Nickname:
Middle School:
Home Room Teacher:
Counselor:
High School you will attend:
Street Address:
Phone:
City:
State:
Zip:
Email:
Date of Birth:
Sex:
M
F
Student ID:
Optional: With which ethnic group do you identify:
Native American
Caucasian
Asian
African American
Hispanic
Other:
Family Information
Information on adults with whom you reside:
Name of Father/Stepfather/Guardian:
Name of Mother/Stepmother/Guardian:
Occupation:
Occupation:
Employer:
Employer:
Email:
Email:
Highest Level of Education: (USA or Abroad)
Highest Level of Education: (USA or Abroad)
years in High School
years in High School
High school diploma
High school diploma
GED
GED
2-Yr. college diploma (AA)
2-Yr. college diploma (AA)
4-Yr. college diploma (BS/BA)
4-Yr. college diploma (BS/BA)
Degrees beyond BS/BA or
Degrees beyond BS/BA or
Certifications:
Certifications:
Degrees Earned outside US (School Attended)
Degrees Earned outside US (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
Please list any languages other than English spoken at home:
No
No
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’ guidance
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:
Parent Comments:
Date:
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 the 8th grade counselor no later than March 15, 2013.
The student named above is applying to participate in CAMPUS, a Loudoun County Public Schools’ Guidance
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, and others may need
support and nurturing. Students should demonstrate respectful behavior towards peers and staff members.
Your responses to the questions below will be added to the student application, writing sample, scholastic record,
and parent/guardian comments 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 which will 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 the 8th grade counselor no later than March 15, 2013.
The student named above is applying to participate in CAMPUS, a Loudoun County Public Schools’ Guidance
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, and others may need
support and nurturing. Students should demonstrate respectful behavior towards peers and staff members.
Your responses to the questions below will be added to the student application, writing sample, scholastic record,
and parent/guardian comments 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 which will be helpful for the selection committee to know.
Thank you for your support and assistance.
Rising 9th Grade CAMPUS Student
Contact Information Form
2013/2014
Student first & last name:
High school he/she will attend:
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.