Excellerate Parent Intake Form

1

Parent/Guardian 1 Name* This field is required.

2

Parent/Guardian 1 Occupation* This field is required.

3

Parent/Guardian 1 Phone* This field is required.

4

Parent/Guardian 1 Email* This field is required.

5

Parent/Guardian 1 Home Address* This field is required.

6

Do you want to add Parent or Guardian 2 Contact Information?

YESNO

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Parent/Guardian 2 Name

8

Parent/Guardian 2 Occupation

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Parent/Guardian 2 Phone

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Parent/Guardian 2 Email

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Parent/Guardian 2 Home Address(if different from above)

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Student Full Name* This field is required.First Last (Nickname, if applicable)

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Student Date of Birth* This field is required.

Date

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Student Email Address* This field is required.

15

Student Phone Number* This field is required.

16

Student's Legal Status* This field is required.Note: This information is for Excellerate only and will not be shared with anyone else. *Why does Excellerate need to know about the student's legal status? A majority of our students are domestic students. However, we have a good number of international students we work with, so this information is helpful to know for the roadmap planning.

U.S. Citizen

International Student Visa

Other

17

What is the student's current grade level?* This field is required.

18

Student's School Name* This field is required.

19

Student's Current Grade* This field is required.ex: 5th grade

20

Please upload student's latest assessment results.NWEA MAP, STAR, Terra Nova, etc. Please include both Math, Reading/Language Arts

Drag and drop files here

Select files to upload

21

If this student stays in the same school district, which middle school will this student attend?* This field is required.

22

If this student stays in the same school district, which high school will this student attend?* This field is required.

23

What do you think is your student's favorite subject, and why?* This field is required.Please feel free to discuss with your child and list as many reasons they give.

24

What do you think is a subject in which your student struggles the most, and why? * This field is required.If applicable

25

In what areas has the student shown interest or strength outside of school? What's so special about this child?* This field is required.ex: activities, talents, skills, etc.

26

In what services provided by Excellerate are you interested?* This field is required.Please check all that apply

Group Core Academic (K-8) - Math/English

Group Academic Enrichment (K-9) - Writing/STEM

1:1 Academic Coaching (1-12) - School Subject or Core Academics

College Planning Consulting

Other

27

Student's School Name* This field is required.

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Student's Current Grade* This field is required.ex: 7th grade

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Please upload student's latest assessment results.NWEA MAP, STAR, Terra Nova, etc. Please include both Math, Reading/Language Arts

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

30

If this student stays in the same school district, which high school will this student attend?* This field is required.

31

Please list all courses the student is taking this year: first and second semester.Plus grades, if possible. For example: Honors Pre-Algebra (A-); Regular English (B); Orchestra (A); etc.

32

Please list any extracurricular or co-curricular activities. Such as clubs, jobs, volunteering experiences, hobbies, etc.

33

Tell us special quality about this child beyond grades and activities.

34

Has the student taken any standardized exams, such as SSAT, PLAN, PSAT, etc.?Please enter all that apply, along with breakdown of scores if possible. For example, "PLAN: 22 Composite, 20 English, 24 Math, 19 Reading, 23 Science."

35

In what areas has the student shown interest, talent, or strength? For example: sports, instruments, college major and/or career, etc.

36

Have you considered or discussed college options? If so, which colleges or universities would you (student and/or family) consider as target schools? Dream schools?List as applicable

37

Are you considering applying to a private high school or boarding school?

Yes - Most likely will consider

Maybe - might consider

No - will not consider

38

In what services provided by Excellerate are you interested?* This field is required.Please check all that apply

Group Core Academic (K-8) - Math/English

Group Academic Enrichment (K-9) - Writing/STEM

Group ACT/SAT/PSAT Prep (8-12)

1:1 ACT/SAT/PSAT Prep

1:1 Academic Coaching for School/Study Skills Support

College Consulting

Other

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Student School Name* This field is required.

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Student Graduation Year* This field is required.

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Student's Counselor's NameIf applicable

42

Student's WEIGHTED GPA and Scaleex: 4.2 / 5.0

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Student's UNWWEIGHTED GPA and Scale* This field is required.ex: 3.5 / 4.0

44

High School Transcript* This field is required.Please an upload unofficial HS transcript to show the entire course work and grades.

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Select files to upload

Max. file size: 10.6MB

45

Honors courses taken (and grade when taken)ex: Honors Chemistry (9th); Honors English (8th & 9th). You don't need to answer this if you already uploaded a copy of the transcript.

46

AP courses taken (with AP Test score, if applicable)ex: AP US History (4); AP Calculus AB (5) You don't need to answer this if you already uploaded a copy of the transcript.

47

List any academic, art, or other honors and distinctions (if applicable)ex: National Honors Society, Rube Goldberg State Champion

48

List any extracurricular or co-curricular activitiesSuch as clubs, jobs, volunteering experiences, hobbies, etc

49

Has the student participated in any college programs? If so, please enter name of school & program title/course taken.

50

Has the student taken any standardized exams, such as PLAN, ACT, PSAT, etc.?Please enter all that apply, along with breakdown of scores if possible. For example, "ACT: 25 Composite, 22 English, 28 Math, 24 Reading, 26 Science, 8 Writing."

51

Student's field of interest or potential majorsEnter up to 4 as applicable

52

To which colleges or universities are you (student and/or family) interested in applying? List as applicable

53

In what services provided by Excellerate are you interested?* This field is required.Please check all that apply

Group High School Core Academic - Math/English

Group ACT/SAT/PSAT Prep (8-12)

1:1 ACT/SAT/PSAT Prep (8-12)

1:1 Academic Coaching: School/Study Skills Support (K-12)

College Consulting, including essays

Other

54

Current College/Grad School Name* This field is required.

55

Intended Major(s)* This field is required.

56

Estimated Graduation YearIf applicable

57

Past math subjects takenChoose all you have taken in high school and/or college or beyond.

High School Algebra 1 & 2

Calculus (1st year)

Statistics

Other

58

Post Graduation Goals or Plans* This field is required.

Graduate school

Profession Degree (Health-related)

Professional Degree (Law-related)

Doctorate Degree

Seeking job or career upon graduation

Other

59

List any extracurricular or co-curricular activitiesSuch as clubs, jobs, volunteering experiences, hobbies, interests, etc.

60

유학의 동기와 목적

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유학이을 결정하는 동기와 궁극적인 목표를 서술해 주십시오

62

학생의 해외 유학및 여행 경험을 나열해 주십시오

63

미국에 있는 친척과 친지가 있으면 성함과 연락처를 나열해 주십시오.

64

토플이나 이외 입시 시험 (GRE등)을 본적이 있으면 시험의 종류와 점수를 입력해 주십시오.

65

부모님이나 학생이 생각하시는 성공적인 유학생활이란?

실용 영어를 유창하게 하여 친구들과 재미있게 지내는것

학습 영어를 습득하여 고등학교 및 대학교/대학원 지원시 우대를 받는것

대학교 졸업후 미국에서 안정적인 직장을 잡아 자리잡을 수 있는 기반이 되는것

대학교 졸업후 한국에 돌아와 안정적인 직장을 잡아 자리잡을 수 있는 기반이 되는것

한국에서의 일률적인 교육방식과는 달리 개인의 특징과 장기, 인성을 살릴 수 있도록 돕는 교육을 받는것

66

유학 하고자 하는 기간

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미국에서 시작하게 될 학년한국에서 바로 오는 학생이면 나이로 기준

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Parents' Marital Status

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Family (Household) Size

75

[For a family of a current high school student who is concerned about college financial aid only] Family Adjusted Gross Income Based on the most recent income tax information

76

Do you have any other household members (such as siblings) other than parents that you want to add?

YESNO

77

Relationship to Student

78

First Name (Plus last name if different)

79

Age

80

In College? (Yes or No. If yes, name of the school)

81

Do you have another family member you'd like to add?

YESNO

82

Relationship to Student

83

First Name (Plus last name if different)

84

Age

85

In College? (Yes or No. If yes, name of the school)

86

Do you have another family member you'd like to add?

YESNO

87

Relationship to Student

88

First Name (Plus last name if different)

89

Age

90

In College? (Yes or No. If yes, name of the school)

91

Do you have another family member you'd like to add?

YESNO

92

Relationship to Student

93

First Name (Plus last name if different)

94

Age

95

In College? (Yes or No. If yes, name of the school)

96

Do you have another family member you'd like to add?

YESNO

97

Relationship to Student

98

First Name (Plus last name if different)

99

Age

100

In College? (Yes or No. If yes, name of the school)

101

What are some of the biggest concerns or most pressing needs you have that you would like us to address during our initial consultation?* This field is required.

103

Please Check to Acknowledge:* This field is required.

We certify that the information provided is accurate to the best of our knowledge. By checking this box, we grant Excellerate Learning Studio permission to send us additional communications via text or email.

104

Date Completed:* This field is required.Please enter today's date.

Date