Sampson Early College High School

Application for Rising 9^th Graders

The undersigned student is applying for acceptance with SECHS and agrees to abide by the rules and expectations set by Sampson Community College and the administrators, guidance counselor, and teachers of the early college program. You understand that the SECHS program will require commitment and effort for a minimum of one semester. If at the end of any high school year a SECHS student is unable or unwilling to continue studies at Sampson Community College through the early college program he/she will be reassigned to the high school in his/her attendance zone. Sampson Early College students must adhere to Sampson Community College and the high schools policies. By signing and submitting this application the parent(s) / legal guardian(s) and the student understand that behavior or attendance problems will be sufficient cause to be withdrawn from SECHS.

Student Name: _______________________________________________________

Date of Birth: ___________________ Social Security Number: ________________

How did you hear about SECHS? __________________________________________

Student Resides with
	_____ Both Parents	_____ Mother	_____ Father	_____ Relative (_______)
	_____  Legal Guardian	_____ Emancipated

Parent (s) / Legal Guardian: ______________________________________________

Home Street Address: ___________________City ____________ Zip ____________

Mailing Address (if different)______________________________________________

Home Phone: _____________ Cell Phone:______________ Alt. Phone: ____________

Email: ________________________________________________________________

Mother’s Place of Work: _______________________________ Phone: ___________

Father’s Place of Work: _______________________________ Phone: ___________

School presently attending: ___________________________________

What is your career plan? __________________________________________________

FOR OFFICE USE ONLY:

Student is recommended for SECHS _____ Yes _____ No

Student is # ________ on the waiting list for SECHS

Pg 2 Sampson Early College Application

Why is Sampson Early College High School the right choice for you? _______________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

What problems (personal, social, academic, or discipline) have you had in your school experiences? Be specific. __________________________________________________

________________________________________________________________________

________________________________________________________________________

____________________________________________________________

Do you consider yourself a mature candidate for the early college program? Why/why not? Defend your answer __________________________________________________

________________________________________________________________________

________________________________________________________________________
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References. Two references should be from staff members at your current school.

The third reference should be someone who can speak to your character traits within the community. (Do not list family members)
References are available on-line at http://earlycollege.sampsoncc.edu/

Reference #1:	Name ____________________________________
	Address __________________________________
	Phone ____________________________________
Reference #2:	Name ____________________________________
	Address __________________________________
	Phone ____________________________________
Reference #3:	Name ____________________________________
	Address __________________________________
	Phone ____________________________________

PARENT(S)/LEGAL GUARDIAN SIGNATURE REQUIRED TO PROCESS
:

Authorized Signature: Date:

Student Signature: Date: