Student Application by ROAoRY4

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                            Official Application
     2009 West Virginia Governor’s School for Mathematics and Science

                            PERSONAL INFORMATION

Grade ________________

7th-grade students will attend the session at WVU
8th—Sessions are held at WVU and at the National Radio Astronomy Observatory
(NRAO). Please write either “YES” or “NO” in the blank following the name of
each session. (See more specific directions on the application web page)

WVU__________________             NRAO _________________


Legal Name: _____________________________________________________
                   Last                First               Middle Initial
Nickname: __________________________Date of Birth: ________________


Address: ______________________________________________________________


City ___________________ State _______ZIP __________County ______________


E-Mail Address ___________________________Home Phone___________________


Cell phone for reaching parents __________________________________


School You Attend ______________________________________________________


Name of Parent(s) or Legal Guardian_______________________________________


Work Phone: Mother _____________________ Father _______________________


Home Phone (if different from your home phone)
             Mother _______________________Father ______________________



 The following information is being requested to ensure equal access opportunity

             Gender________________      Ethnicity _______________
PAGE 2


                      2009 STUDENT APPLICATION
           GOVERNOR’S SCHOOL FOR MATHEMATICS AND SCIENCE

  1. List below any awards, honors and school or instructional activities in which you
     are or have been involved. You may include civic and/or church activities. At the
     end, list other activities that interest you.




  2. In the space below, please list special interests in the areas of science or
     mathematics. Some examples follow: Biology, Physics, Chemistry, Engineering
     Science, Agricultural Science, Computer Science, Health Sciences, Medicine,
     Aeronautics, etc. List any special math/science projects you have been involved in
     or have dreamed about. Such interests could also include long-term care of small
     animals, model rocket or airplane flying, science fair projects, Odyssey of the Mind,
     Science Olympiad teams, etc.




     3. What are some changes that science has brought about in your thinking?
     You may continue this answer on another page.
PAGE 3

                      2009 STUDENT APPLICATION
           GOVERNOR’S SCHOOL FOR MATHEMATICS AND SCIENCE


  4. Have you produced, created or invented something that has made you proud?
     Describe it in the space that follows.




  5. In the space below, write a well developed paragraph that tells why you think you
     should be selected for the Governor’s School for Mathematics and Science.
     Remember that a paragraph has a good topic sentence and at least five more
     sentences to back it up.
PAGE 4

                      2009 STUDENT APPLICATION
           GOVERNOR’S SCHOOL FOR MATHEMATICS AND SCIENCE


Please sign below to indicate your consent to release the student’s name,
photograph, and information to organizations or news media, including the Internet,
that are interested in recognizing and/or supporting scholarly efforts. This may
include sending your mailing address to educational institutions.




Student Signature                                                Date




Parent/Guardian Signature                                          Date
Please sign below to indicate that you agree to a full-time commitment for the
duration of the Governor’s School for Mathematics and efforts. If you are chosen
for another honor during this period you must choose between the two.




Student Signature                                                Date




Parent/Guardian Signature                                        Date

Please sign below to indicate your consent to participate in and to abide by the
regulations of the West Virginia Governor’s School for Mathematics and Science.




Student Signature                                                Date




Parent/Guardian Signature                                        Date
PAGE 5
                    2009 STUDENT APPLICATION
             GOVERNOR’S SCHOOL FOR MATHEMATICS AND SCIENCE

             PERMISSION TO SHARE/TRANSPORT APPLICATIONS
Student records and applications are kept in the Governor’s Schools office at the
Department of Education and the Arts except when it is necessary to take them off site for
review. Your agreement to the following statement signifies that you are aware of this
process. We always take every precaution possible to safeguard your child’s records, and
there has not been an incident with Governor’s Schools applications. More stringent rules
about maintaining privacy necessitate this step.

I hereby give permission for Director of Governor’s Schools to transport my child’s
Governor’s Schools application to the site where members of a committee will read it. In
addition to personal statements and references, the application includes personal identity
information, as well as a transcript of his/her grades. It shall not include a Social Security
Number. I understand that the selection team will keep all information confidential and
that my child’s application will not be discussed outside the meeting.


_______________________________Student Name (Print or type)

_______________________________Parent Signature                       ___________Date

_______________________________Student Signature ___________Date




    Submit the completed application to the appropriate person at your school.

                Be sure to check with your counselor for the due date.
Page 6
                         2009 STUDENT APPLICATION
              GOVERNOR’S SCHOOL FOR MATHEMATICS AND SCIENCE

Teacher#1 Recommendation Form

Student’s Name: ______________________________________________
Teacher’s Name: _______________________________________________
School: ______________________________School Phone ____________
Principal Subject(s) Taught: ______________________________________

Students attending the Governor’s School for Mathematics and Science are to be selected
based upon a special interest in or propensity for math or science. The committees shall
also consider interpersonal skills, task persistence, motivation, creativity, general maturity
and emotional maturity. In the space below, describe the student in reference to these
areas in order to assist the selection committees in making the final selection. The second
part of the recommendation (p 6) is a checklist.

Interest in Science/Mathematics :




Achievement:




Interpersonal skills:




Task Persistence




Motivation:




Creativity:



General and Emotional Maturity:
Page 7
                          2009 STUDENT APPLICATION
               GOVERNOR’S SCHOOL FOR MATHEMATICS AND SCIENCE


Teacher #1 Recommendation Checklist

Compared with other superior students you have taught, please estimate the extent to which

you have observed the nominee demonstrating the qualities listed below by circling the

number that best represents his/her performance.


             (5 =Excellent; 4=Very Good; 3=Good 2=Average; 1=Below Average)*


Intellectual Curiosity                               5      4       3      2       1

Independence of Thought                              5      4       3      2       1

Originality of Thought                               5      4       3      2       1

Persistence of Effort                                5      4       3      2       1

Motivation                                           5      4       3      2       1

Writing ability                                      5      4       3      2       1

Speaking ability                                     5      4       3      2       1

*An Average of 3.0 or better is necessary for a student to be considered for participation

The Governor’s School is an intensive residential experience, and there will be no family
visitations. Consider personal qualities or behaviors that might make it difficult for the
named student to adjust to this type of living and learning environment when making your
recommendation. An explanation should accompany minor reservation and major
reservation recommendations.


I recommend this student to the Governor’s School for Mathematics and Science

_____Without reservation

____With minor reservations

____With major reservations

Teacher’s Signature ________________________________________

Date __________________
Page 8

                         2009 STUDENT APPLICATION
              GOVERNOR’S SCHOOL FOR MATHEMATICS AND SCIENCE



Teacher #2 Recommendation Form

Student’s Name: ______________________________________________
Teacher’s Name: _______________________________________________
School: ______________________________School Phone ____________
Principal Subject(s) Taught: ______________________________________

Students attending the Governor’s School for Mathematics and Science are to be selected
based upon a special interest in or propensity for math or science. The committees shall
also consider interpersonal skills, task persistence, motivation, creativity, general maturity
and emotional maturity. In the space below, describe the student in reference to these
areas in order to assist the selection committees in making the final selection. The second
part of the recommendation (p 8) is a checklist.

Interest in Science/Math:



Achievement:



Interpersonal skills:



Task Persistence:



Motivation:




Creativity:




General and Emotional Maturity:
Page 9

                          2009 STUDENT APPLICATION
               GOVERNOR’S SCHOOL FOR MATHEMATICS AND SCIENCE



Teacher #2 Recommendation Checklist

Compared with other superior students you have taught, please estimate the extent to which

you have observed the nominee demonstrating the qualities listed below by circling the

number that best represents his/her performance.


             (5 =Excellent; 4=Very Good; 3=Good 2=Average; 1=Below Average)*


Intellectual Curiosity                               5      4       3      2       1
Independence of Thought                              5      4       3      2       1
Originality of Thought                               5      4       3      2       1
Persistence of Effort                                5      4       3      2       1
Motivation                                           5      4       3      2       1
Writing ability                                      5      4       3      2       1
Speaking ability                                     5      4       3      2       1


*An Average of 3.0 or better is necessary for a student to be considered for participation

The Governor’s School is an intensive residential experience, and there will be no family
visitations. Consider personal qualities or behaviors that might make it difficult for the
named student to adjust to this type of living and learning environment when making your
recommendation. An explanation should accompany minor reservation and major
reservation recommendations.

I recommend this student to the Governor’s School for Mathematics and Science

_____Without reservation

_____With minor reservations

_____With major reservations

Teacher’s Signature _________________________________Date __________________
Page10
                         2009 STUDENT APPLICATION
             GOVERNOR’S SCHOOL FOR MATHEMATICS AND SCIENCE
                To Be Completed By School Counselor or Principal


Student
Name

1. A ranking of Above Mastery or higher in science
or mathematics on the most recent WESTEST             1. Science M AM D
(Circle appropriate scores), or a score at 90th          Math    M AM D
percentile on a nationally normed test (name test
and designate percentile                              Other ______________


2. B+ Average in science or mathematics for the       2. Science Average ______
current or previous year                                 Math Average ________


              (Check off #3-7)
                                                      3. ______________
3. No semester grade below a C since 6th grade

4. Two (2) Teacher recommendation forms
                                                      4. ______________
(attached)

5. Photocopies of WESTEST (or other national
standardized test) and all other available test       5. ______________
scores.

6. Photocopy of transcript of grades for middle
                                                      6. ______________
school


7. Copy of this year’s schedule and grades            7. ______________



       PRINCIPAL MUST FILL OUT AND SIGN THE FOLLOWING STATEMENT

 I recommend the above-named student.

 Without reservation _________                    _____________________________
 With slight reservation _______                             Signature


*Only students who are recommended without reservation should be considered at
the county level. If a principal recommends a student with reservation, he/she must
submit a statement with the reasons for such.

								
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