Dear Applicant,
Thank you for your interest in Breakthrough Atlanta! We are dedicated to providing our
students with a world-class enrichment experience in a setting that is friendly, warm,
supportive, and academically charged. Breakthrough has a long tradition of training
middle school students who go on to achieve success and become leaders in their
respective schools, communities and even their own households. All Breakthrough
Atlanta students are encouraged to pursue, engage in and become leaders in scholarly
activities.
Breakthrough Atlanta is a part of a national collaborative that consists of 33 sites
throughout the United States and one in Hong Kong. We operate out of two campuses
in Atlanta: The Lovett School and the Atlanta Youth Academy. We have a dual mission:
1) To place middle school students from metropolitan Atlanta’s public schools on a six
year path to college. 2) To inspire the next generation of teachers by providing a
summer teaching internship for college students from around the country. Our staff is
dedicated to our motto of “College (period)” and we strongly believe that our model of
“Students Teaching Students” creates a special chemistry, which must be approached
with much care and dedication. We provide all of our students with individualized
training and mentoring so that they can pursue their highest aspirations, whether in
medicine, law, education or whatever path they choose.
Breakthrough Atlanta has been developed as an innovative model for integrating
students in a way that dramatically improves both social and educational outcomes. In
our summer and school-year programs, students work with college-age students who
aspire to make a difference in our community. The teacher interns are supported by
certified teachers who bring a variety of educational experiences.
Finally, as a program, we feel strongly connected to the community we serve. Our
students and teachers reach out in many ways to serve beyond the walls of The Lovett
School and the Atlanta Youth Academy. They serve as leaders who commit to
community service throughout the city
Again, thank you for your interest in Breakthrough Atlanta. We feel that we offer a
superior enrichment experience and we hope that you will consider us as the way to
foster your student’s love, passion and excitement for education.
Sincerely,
Jeremy J. Crane
Jeremy J. Crane
Program Director
Breakthrough Atlanta
4075 Paces Ferry Rd. NW, Atlanta, GA 30327 • 404-262-3032 ext 1447 • Fax 404-479-8465
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Breakthrough Calendar
Session
Date
Location
Time
Student group interviews
(half hour intervals)
April 11, 2015
9:00am -4:00pm
Acceptance Notifications
April 17, 2015
Atlanta Youth Academy
&
The Lovett School
Email & mailings to families
Enrollment Packet Return
Deadline Date
Student/Family Summer
Orientation
Student/Family Summer
Orientation
Summer Program Begins
May 5, 2015
The Lovett School
June 13, 2015
Atlanta Youth Academy
Close of Business Day
5pm
9:00am
June 13, 2015
9:00am -12:00pm
2:00pm -4:00pm
End of Summer Reception
July 25, 2015
The Lovett School
Glover Gym
Lovett School & Atlanta
Youth Academy
Atlanta Youth Academy
End of Summer Reception
July 25, 2015
The Lovett School
June 15, 2015
N/A
1:00pm
7:45am - 3:30pm
Application Deadline: February 9, 2015
APPLICATION CHECKLIST

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STUDENT INFORMATION SECTION (completed by student)
STUDENT’S FAMILY INFORMATION – 2 PAGES (completed by student and parent/guardian)
EDUCATIONAL RELEASE (signed by parent or guardian)
RECOMMENDATIONS
STUDENT’S CURRENT REPORT CARD
STUDENT’S STANDARDIZED TEST SCORES (CRCT, ITBS etc.)
*PLEASE NOTE: INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED.
FAMILIES/STUDENTS: Keep this page for your information.
4075 Paces Ferry Rd. NW, Atlanta, GA 30327 • 404-262-3032 ext 1447 • Fax 404-479-8465
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Student Section
On my honor I, ______________________________, agree to complete the following application in my own handwriting with a pen
and without significant help.
SIGNATURE: ____________________________________________________________
Student’s Name______________________________________________________________________________
Last
First
Middle
Date of Birth____________________ Place of Birth__________________________________________________
City
State/Province
Country
Male_______ Female_______ Current Grade ______ T-shirt Size: Adult _____ Child______
Social Security Number ________________________________________
(Note, this information is confidential and does not determine whether you are accepted or not)
Primary/Home Telephone # (____)___________________
Cell Phone (
) _________________________
Student’s E-mail___________________________________________________________________________
Home Address ___________________________________________________________________________
Number and Street
Apartment
_____________________________________________________________________________
City
State
Zip
Current School_____________________________________________________________________
English Teacher ___________________________________________________________________________
First Name
Last Name
Current School
Math Teacher______________________________________________________________________________
First Name
Last Name
Current School
Ethnicity (Check All That Apply):



Caucasian
African American
West Indian



Hispanic/ Latino(a)
South Asian
East Asian



Native American
South East Asian
Eastern European
4075 Paces Ferry Rd. NW, Atlanta, GA 30327 • 404-262-3032 ext 1447 • Fax 404-479-8465
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Parent Section
_____________________
__________________
Student’s First and Last Name
Student’s School
Parent #1 or Guardian #1
Full Name:______________________________
First Name
__________________
Last Name
Relationship to Student
Home Address: _______________________________________________________________________________
Number and Street
Apartment
____________________________________________________________________________
City
State
Zip Code
Primary/Home Telephone (______)_____________________ Cell Phone (_____)_______________________
Work Telephone (______)____________
E-mail _________________________________________________
Highest Grade Completed in School _______________________________
Language(s) Spoken at Home ____________________________________________
Occupation _______________________________ Employer ___________________________
Parent #2 or Guardian #2
Full Name:______________________________________________________
First Name
Home Address:
Last Name
Relationship to Student
____________________________________________________________________________
Number and Street
Apartment
____________________________________________________________________________
City
State
Primary/Home Telephone (______)_____________________
Zip Code
Cell Phone (_____)_____________________
E-mail ____________________________________Work Telephone (_____)_______________
Highest Grade Completed in School ________________________________
Language(s) Spoken at Home ____________________________________________
Occupation _______________________________ Employer ____________________________
4075 Paces Ferry Rd. NW, Atlanta, GA 30327 • 404-262-3032 ext 1447 • Fax 404-479-8465
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Family Status
The student lives with: (Check all that apply.)
 father  mother  grandfather  grandmother  guardian
 step-father  step-mother  other (please specify): ________
The parents of the student are (Check all that apply.)
 married
 separate
 mother deceased
 divorced  father deceased
Is your student a citizen of the United States?
 Yes
 No
Family Education
1.
Would your child be first in her/his **immediate family** to attend a 4-year college in the United
States?
(Check Yes or No)
 Yes
 No
If no, please indicate who in the immediate family (including yourself) has attended college and where:
**immediate family pertains to father, mother or siblings
Relationship to Student
Name of University
Years Attended
Type of Degree
The information requested below is required information. If the information requested is not
provided, then your applicant cannot be considered for acceptance into the program.
2.
3.
4.
5.
6.
7.
8.
Do you rent or own your home?
How many family members reside in your home? _________
(Check “Rent” or “Own””)
 Rent  Own
Estimated Annual Household Income: $______________
Does student qualify for free or reduced lunch?
 Yes
 No
Do you have another child in the program?
 Yes
 No
Do you have another child in the program? If yes, name_______________________________________
4075 Paces Ferry Rd. NW, Atlanta, GA 30327 • 404-262-3032 ext 1447 • Fax 404-479-8465
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Grade Release Form
(Parent/Guardian is responsible for obtaining educational records.)
To the Parent or Guardian: Please fully complete this form before submitting it to your
child’s current school.
___________________
______________________________
Student’s First and Last Name
Date of Birth
Student’s Current School
____________________________________________________________
Address of Student’s Current School
PARENT OR GUARDIAN PERMISSION
I authorize my child’s school to release the complete educational record of my child to Breakthrough Atlanta hosted
at The Lovett School. I also give permission for Breakthrough Atlanta to access my child’s future academic records.
Name of parent or guardian: ___________________________________________________________
Signature of parent or guardian: ________________________________________________________
Date: _____________
To the School:
This student is applying to Breakthrough Atlanta, a tuition-free, six-year academic
enrichment program at The Lovett School and Atlanta Youth Academy. Breakthrough Atlanta
seeks motivated students to participate in its program, which includes a Saturday School Year
Program and a Summer Program. If you have any questions regarding our program, please go
to www.breakthroughatlanta.org or call us at 404-262-3032.
Please give us a complete record of the applicant’s grades from the last academic
year and most recent standardized test scores. To ensure confidentiality, this release has
been signed by the applicant’s parent or guardian as part of the application process to
Breakthrough Atlanta. Please fax or mail this form and the accompanying information to the fax
number or address, respectively, located at the bottom of this page.
4075 Paces Ferry Rd. NW, Atlanta, GA 30327 • 404-262-3032 ext 1447 • Fax 404-479-8465
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Math Teacher Recommendation
Student’s Name:__________________________________
School:_________________________________________
Math Teacher’s Name:_____________________________
Dear Math Teacher,
Your student is applying to Breakthrough Atlanta—a tuition-free, six-year academic preparation
program The Lovett School and Atlanta Youth Academy. The program seeks motivated, enthusiastic, and
hardworking students to participate in its program, which takes place for six weeks during the summer
and two Saturdays per month during the school year. Breakthrough is committed to a diverse student
body representing the variety of ethnic, economic, and geographic backgrounds in the metro Atlanta area.
We would appreciate candid responses, which will be kept confidential. Please return this form as soon
as possible to the address below:
Breakthrough Atlanta
4075 Paces Ferry Road, NW
Atlanta, GA 30327
Office 404-262-3032 ext. 1443
Fax 404-479-8465
Please rate the student’s academic and personal attributes in relation to the other students you
have taught.
One of the top
few I have ever
encountered
Excellent
(top 2%
this year)
Very
Good
(top 10%
this year)
Good
(Above
Average)
Average
Below
Average
Skill Level (general)
Basic Arithmetic
6th or 7th Grade Math Comprehension
Analytical Thinking
Motivation & Effort
Please consider: self-motivation, intellectual curiosity,
enthusiasm for learning, focus, class participation and
work ethic.
Citizenship
Please consider: group work, respect for classmates
and community.
Behavior (Brief statement)
In the space to the right, please provide a brief
statement that reflects on the applicants behavior.
Consider the applicants respect for class rules, past
behavioral incidents, kindness towards others, ability
to lead and attitude when presented with academic
challenges.
4075 Paces Ferry Rd. NW, Atlanta, GA 30327 • 404-262-3032 ext 1447 • Fax 404-479-8465
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10
English Teacher Recommendation
Student’s Name:__________________________________
School:_________________________________________
English Teacher’s Name:_____________________________
Dear English Teacher,
Your student is applying to Breakthrough Atlanta—a tuition-free, six-year academic preparation
program The Lovett School and Atlanta Youth Academy. The program seeks motivated, enthusiastic, and
hardworking students to participate in its program, which takes place for six weeks during the summer
and two Saturdays per month during the school year. Breakthrough is committed to a diverse student
body representing the variety of ethnic, economic, and geographic backgrounds in the metro Atlanta area.
We would appreciate candid responses, which will be kept confidential. Please return this form as soon
as possible to the address below:
Breakthrough Atlanta
4075 Paces Ferry Road, NW
Atlanta, GA 30327
Office 404-262-3032 ext. 1443
Fax 404-479-8465
Please rate the student’s academic and personal attributes in relation to the other students you
have taught.
One of the top
few I have ever
encountered
Excellent
(top 2%
this year)
Very
Good
(top 10%
this year)
Good
(Above
Average)
Average
Below
Average
Skill Level (general)
Basic Arithmetic
6th or 7th Grade Math Comprehension
Analytical Thinking
Motivation & Effort
Please consider: self-motivation, intellectual curiosity,
enthusiasm for learning, focus, class participation and
work ethic.
Citizenship
Please consider: group work, respect for classmates
and community.
Behavior (Brief statement)
In the space to the right, please provide a brief
statement that reflects on the applicants behavior.
Consider the applicants respect for class rules, past
behavioral incidents, kindness towards others, ability
to lead and attitude when presented with academic
challenges.
4075 Paces Ferry Rd. NW, Atlanta, GA 30327 • 404-262-3032 ext 1447 • Fax 404-479-8465
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