MIDDLE CREEK HIGH SCHOOL APPLICATION FOR THE
ENGINEERING & DESIGN ACADEMY 2016-2017
Parent/Guardian must complete this page of the application. Please print clearly in black/blue ink. Student
must complete the following pages. Applications from students to attend the Engineering & Design Career
Academy will only be processed if the student is assigned to Middle Creek High School. For additional
information contact Karen Ingram, Academy Coordinator at 919-773-3864 or email me at Kingram2@wcpss.net.
Name of Student_________________________________________ Sex_____
Race_____________________
Age_________ Date of Birth_______________________________
Name(s) of Parent/Legal Guardian that student resides with _______________________________________
Student’s Home Address ____________________________________________________________________
(street)
____________________________________________________________________
(City, State, Zip)
Mother/guardian
TELEPHONE NUMBERS
Residence Phone:
Work Phone:
Cell:
Father/guardian
Residence Phone:
Cell:
Student
Residence Phone:
Work Phone:
Cell:
EMAIL ADDRESS
Mother/guardian
Father/guardian
Student
Courses taken during the previous school year:______________________________________________________
____________________________________________________________________________________________
List clubs, extracurricular activities, family activities, and hobbies that you are currently involved in or plan to
engage in while being an academy student:
Sport(s)
Club(s)
Family Activities
Hobbies
Please answer the following questions to the best of your ability.
What are your career goals? _____________________________________________________________________
____________________________________________________________________________________________
What is your greatest strength? __________________________________________________________________
What is one of your weaknesses?_________________________________________________________________
What three words (or two phrases) come to mind when you think of yourself? Explain your answer.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Have you ever been expelled, on probation, suspended and/or removed from school due to a disciplinary issue?
YES/NO If YES, please describe. (Failure to provide this information could result in placing your application in
jeopardy of not being accepted.)__________________________________________________________________
_____________________________________________________________________________________________
This is a rigorous program, are you committed to working hard?_________________________________________
Participating in an internship is a requirement for membership in this academy. You and your parent will be
required to sign a contract committing to fulfilling this requirement. Are you willing to sign the contract and abide
by this requirement? _________
Students coming in to the academy will be required to purchase Academy polo shirts which are $20 are you willing
to make this purchase if accepted into the Engineering & Design Academy? ___Yes
___No
Please write 2-3 brief paragraphs on why you are interested in the Engineering & Design Academy
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Please have two of your current teachers to complete the teacher’s recommendations that are attached.
MCHS Engineering & Design Academy Recommendation
To the applicant: Please complete the top section and give this form to one of your current classroom teachers
listed in the application, to complete.
Student’s Name _______________________________________________________________________
Last
First
Middle
Student’s Address _____________________________________________________________________
Street
City, State, Zip Code
Student’s Current School ______________________________________________________________________
How long have you know the applicant? ______
In which grade and subject did you teach this applicant? ______________________________________________
What is the applicant’s current grade in your class? I.e., 96 ______
To the Recommender: The student named above is applying for admission to the Engineering & Design Academy at Middle Creek High School.
Please use this form to share with us your perceptions of how well this student will meet the academic and social responsibilities of the
academy. In addition, please attach an official report of discipline issues. Please return this form to the student in a sealed envelope. Thank
you for your assistance.
Please Check as applicable
Exemplary
Acceptable
Needs
Improvement
N/A or
Unknown
Knows how to actively engage in collaborative group
work
Verbal Communication skills
Analytical/Problem-solving
Leadership skills
Overall quality of academic work
Dependability/reliability
Exercises critical thinking skills
Classroom behavior
Interpersonal skills
Cooperativeness
Comments:
Name of Reference_______________________________________
Title_________________________
Department/Organization__________________________________
Phone_______________________
Address_______________________________________________________________________________________
Street
City
State
Zip
Signature_______________________________________________
Date_________________________
MCHS Engineering & Design Academy Recommendation
To the applicant: Please complete the top section and give this form to one of your current classroom teachers
listed in the application, to complete.
Student’s Name _______________________________________________________________________
Last
First
Middle
Student’s Address _____________________________________________________________________
Street
City, State, Zip Code
Student’s Current School ______________________________________________________________________
How long have you know the applicant? ______
In which grade and subject did you teach this applicant? ______________________________________________
What is the applicant’s current grade in your class? I.e., 96 ______
To the Recommender: The student named above is applying for admission to the Engineering & Design Academy at Middle Creek High School.
Please use this form to share with us your perceptions of how well this student will meet the academic and social responsibilities of the
academy. In addition, please attach an official report of discipline issues. Please return this form to the student in a sealed envelope. Thank
you for your assistance.
Please Check as applicable
Exemplary
Acceptable
Needs
Improvement
N/A or
Unknown
Knows how to actively engage in collaborative group
work
Verbal Communication skills
Analytical/Problem-solving
Leadership skills
Overall quality of academic work
Dependability/reliability
Exercises critical thinking skills
Classroom behavior
Interpersonal skills
Cooperativeness
Comments:
Name of Reference_______________________________________
Title_________________________
Department/Organization__________________________________
Phone_______________________
Address_______________________________________________________________________________________
Street
City
State
Zip
Signature_______________________________________________
Date_________________________