Northwestern Academy for Chicago Public Schools
Application Class of 2017
Northwestern Academy is a free, multi-year enrichment program designed to prepare academically talented
Chicago Public School students to successfully matriculate to highly selective colleges and universities.
Northwestern Academy will provide academic year and summer classes, tutoring in academic skills, test
preparation, support from mentors and family workshops, individualized academic support and college
counseling.
To be considered for the Northwestern Academy, students must complete and submit the following requirements
listed below by Friday, February 14th, 2014.
 Complete all sections of the application. Attach separate Word documents of your typed responses to
“Short Takes,” “Short Answers”, and ‘Essays.” Students have the option of completing the application online
or on paper.
 Submit one recommendation form completed by one teacher or your school counselor. The teacher must
be your current teacher in one of the following subjects: Math, Science, or English.
 Submit one data release consent form signed by a parent/guardian. This form will allow Northwestern
Academy to access your academic data, test scores, and quarter grades for your application.
Applications completed on paper must be mailed to the address below or returned to your school’s main office no
later than February 14th, 2014. You may submit the consent form for data release by mail to the address below or
return it to your school’s main office no later than February 14th, 2014.
Northwestern Academy for Chicago Public Schools
Center for Talent Development
School of Education & Social Policy
Northwestern University
625 Noyes Street
Evanston, IL 60208
If selected as a finalist, the student and one parent or guardian must attend an interview on Northwestern
University’s Loop Campus. For information, visit www.academy.northwestern.edu. Contact Cassandra Geiger,
Program Director for Northwestern Academy, at academy@northwestern.edu or 847-467-4471, with any
questions.
Do not submit this page with your application, keep it for your records.
P age 1|9
Northwestern Academy for Chicago Public Schools
Authorization for Release of Academic Data
Name of Student_____________________________________________________________________________________________________
Last
First
Middle
Student ID # _____________________________________________________________________________
High School ______________________________________________________________________________
The Northwestern Academy for Chicago Public Schools is a multi-year academic and cultural enrichment program
to prepare talented, under-resourced students for successful matriculation to highly selective colleges and
universities. Selected students will participate in four consecutive summer programs, cultural excursions and
enrichment during the school year, and receive individualized academic support, career and college counseling at
no cost to the student and parents/guardians.
Acceptance into the Northwestern Academy is based upon careful consideration of the student’s academic
performance, standardized test scores, recommendation and application. Students who demonstrate strong longterm academic potential and are from traditionally under-represented populations in higher education, including
first-generation college students, will be invited to interview with Northwestern Academy staff and members of
the Northwestern University community.
I, _____________________________________ give permission for the release of the following information from Chicago Public
Schools’ records for my child ________________________________________________ to the Northwestern Academy for Chicago
Public Schools as part of the selection process to determine eligibility to participate:



8th Grade end of year assessment data
9th Grade 1st Quarter Grades
9th Grade 2nd Quarter/Semester Grades
I understand that no personally identifiable information will be shared, without permission, outside of
Northwestern Academy and confidentiality will be maintained.
By signing below, you consent to terms and release of data listed above.
__________________________________________________________________________________
Parent/Guardian Signature
_____________________________________________________
Date
P age 2|9
Northwestern Academy for Chicago Public Schools
Application Class of 2017
I. Student information
Name of student _________________________________________________________________________________ Gender (circle one): M F
Last
First
High school ______________________________________________
Middle
Middle school attended _________________________________________
If you applied to CPS Selective Enrollment High Schools, please list in the schools on your application:
____________________________________________________________________________________________________________________________________
Date of birth _____________________________________________
Student email ____________________________________________________
Student permanent address
_______________________________________________________________
Street address
_____________________________________________________________________________
City
______________________________________
Address line 2/apt #
_______________ ______________________
State
Zip Code
Current mailing address, if different from the one above
_______________________________________________________________
Street address
_____________________________________________________________________________
City
Home phone _________________________________________
______________________________________
Address line 2/apt #
_______________ ______________________
State
Zip Code
Student cell phone ___________________________________________
Preferred phone number ___________________________________________________
Where you born in the United States?
Yes
No
(circle one)
If not, what country were you born in? ___________________________________
If not born in the US, how many years have you lived here? ____________
What is the first language you spoke at home? ______________________________________________
List any languages in which you are proficient ________________________________________________________________________
P age 3|9
How do you identify your race/ethnicity? (Please check all that apply and specify below)
 American Indian/Alaskan Native (original peoples of North and South America, Central
America, and who maintains tribal affiliation)
 Asian (including Far East, Southeast Asia, Indian Subcontinent)
 Black or African American (including Africa and the Caribbean)
 Hispanic/Latino (including Cuban, Mexican, Puerto Rican, South or Central American)
 White/Caucasian/Middle Eastern
 Native Hawaiian/Pacific Islander
 Other, please specify _____________________________________
List the countries or cultures of ancestral origins (e.g., Ghana, Haiti, Liberia, Chinese, Sri Lankan, Mexican,
Peruvian, etc.) _________________________________________________________________________________________________________________
P age 4|9
II. Family/Household Information
What is the annual income in your household? (Please note that if you are selected as a finalist, you may be asked
to provide proof of annual income through income tax documents or W2 forms). Please check one.




Less than $10,000
$10,001-$20,000
$20,001-$30,000
$30,001-$40,000
 $40,001-$50,000
 $50,001-$55,000
 More than $55,000
Who is your primary caregiver? Please check one.




One parent - mother or father
Both parents
Parent and stepparent
Grandparent(s)
 One adult guardian:
Relationship ___________________________________
 Two adult guardians:
Relationship ___________________________________
 Other ___________________________________________
Parent/Guardian information:
Name of parent/guardian _________________________________________________________________________________
Last
First
Relationship to student ____________________________________________________________________________________
Mailing address, if different from your address.
_______________________________________________________________
Street address
_____________________________________________________________________________
City
______________________________________
Address line 2/apt #
_______________ ______________________
State
Zip Code
Occupation/Job title ______________________________________________________________________________________
Employer/Company name _______________________________________________________________________________
Work address
_______________________________________________________________
Street address
_____________________________________________________________________________
City
Work phone _______________________________________
______________________________________
Address line 2/apt #
_______________ ______________________
State
Zip Code
Cell phone _____________________________________________
Email address __________________________________________________________________________________________________
Country of birth _______________________________________________________________________________
P age 5|9
Highest level of education obtained (degrees earned, and college attended, if applicable). Select one.
 Below high school
 Some high school
 High school degree
 Some college
 2-year (associate’s)
 4-year (bachelor’s)
 Some graduate or
professional degree
 Graduate or
professional degree
 Other (specify)
_________________________
Parent/Guardian 2 information:
Name of parent/guardian _________________________________________________________________________________
Last
First
Relationship to student ____________________________________________________________________________________
Mailing address, if different from your address.
_______________________________________________________________
Street address
_____________________________________________________________________________
City
______________________________________
Address line 2/apt #
_______________ ______________________
State
Zip Code
Occupation/Job title ______________________________________________________________________________________
Employer/Company name _______________________________________________________________________________
Work address
_______________________________________________________________
Street address
_____________________________________________________________________________
City
Work phone _______________________________________
______________________________________
Address line 2/apt #
_______________ ______________________
State
Zip Code
Cell phone _____________________________________________
Email address __________________________________________________________________________________________________
Country of birth _______________________________________________________________________________
Highest level of education obtained (degrees earned, and college attended, if applicable). Select one.
 Below high school
 Some high school
 High school degree
 Some college
 2-year (associate’s)
 4-year (bachelor’s)
 Some graduate or
professional degree
 Graduate or
professional degree
 Other (specify)
_________________________
P age 6|9
III. Household information
Primary language spoken at home _____________________________________________
Number of family members residing in household ___________________________
Do you rent or own your home? ________________________________________________
List siblings (age, current level of education, name of school, degrees earned and colleges attended if applicable)
Name
Age
Current education
Name of school
Degrees earned
Provide any additional information relating to financial or other circumstances that you believe may be helpful
when considering your application.
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
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P age 7|9
IV. Getting to know you better
Goals. Answer in space provided.
Do you plan to go to college? Select one.
Yes
No
Unsure
Why or why not? ________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
What is the highest level of education you plan to complete?
___________________________________________________________________
Do you have any colleges in mind that you foresee applying to and/or hope to attend? _________________________________
____________________________________________________________________________________________________________________________________
Describe your career interest(s) (if any).
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
Favorite subject(s) in school. __________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
If you could learn about any subject or field, what would it be? ____________________________________________________________
____________________________________________________________________________________________________________________________________
Extracurricular activities you are involved in this year or are interested in pursuing. ___________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
Please provide answers to Short Takes and Short Answer questions on a separate Word document.
Short Takes. Adapted from Yale College’s Application for undergraduate admission. Don’t worry about using
impressive vocabulary words or overly complex sentences. Answer each question in 25 words or less.
1. Favorite book and why?
2. What would you do with a free afternoon tomorrow and if money was not an obstacle?
3. Recall a compliment you received that you especially value. What was it and from whom?
4. What is a question you wish someone would ask you?
Short Answers (Please answer each question in no more than 2 to 5 sentences).
1. Describe a place or environment where you are perfectly content. What do you do or experience there, and why
is it meaningful to you?
2. Who or what inspires you?
3. Describe your academic habits or areas you think need improvement.
4. Why do you want to participate in the Northwestern Academy?
P age 8|9
IV. Essays
*Choose two from the four prompts below. Attach your essays in a separate word document
*Responses should be no more than 1,000 words or two pages in length.
*Please circle the question you are selecting to respond to in your essays.
A. Context
Noun. Late Middle English (denoting the construction of a text): from Latin contextus, from con- ‘together’
+ texere ‘to weave.’ The circumstances that form the setting for an event, statement, or idea, and in terms of
which it can be fully understood and assessed. A frame of reference.
Describe your context. This could be your family, an event or series of events, your culture, and/or
community. How have your circumstances come together to weave or impact what you do, who you are,
what you hope to be? There is no right answer or correct way to answer. You are free to respond by essay,
poem, short story, or illustration(s). (Adapted from the 2013-14 Common Application Essay Prompts).
B. Window
Imagine looking through a window at any environment that is particularly significant to you. Write about
the scene, paying close attention to the relation between what you are seeing and why it is meaningful to
you. (Williams College).
C. Something small
It’s been said that something as small as the flutter of a butterfly’s wing can cause a typhoon halfway
around the world. History is filled with such linchpins – small events or decisions that have huge effects on
the future. Make your own change somewhere in history and show us the effects on the world. (Tufts
University).
D. Matters
Write about what matters to you. It can be a relationship, a place, an idea, a story, a problem, a hope, a fear,
or anything that matters to you that you believe worthy of sharing.
P age 9|9