2021-2022 Core College & Career Readiness Application
Thank you for your application. Please note that your application will not be processed until the non-refundable program fee is received. Once your application is reviewed you will be sent a notification status. Please contact us at info@coreelementscenter.org or 313-473-0787 with any questions. Thank you!
Student Name
*
First Name
Last Name
Student Date of Birth
*
-
Month
-
Day
Year
Date
Student Gender Identity:
*
Student Race/Ethnicity:
*
Student Grade in Fall 2021
*
9th Grade
10th Grade
11th Grade
12th Grade
Returning Student:
*
Yes
No
Student High School Name:
*
Student Email Address:
*
example@example.com
Student Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please list any special needs:
Parent/Guardian Name:
*
First Name
Last Name
Parent/Guardian Phone Number:
*
Parent/Guardian Email Address:
*
Student Signature:
*
Parent/Guardian Signature:
*
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Participant Code of Conduct
Core Elements Higher Education Resource Center is invested in offering a dynamic learning environment to all participants. All members of the core community are entitled to participant in an environment free from threat, discrimination, and other harmful acts. As such, there is an expectation that all members of the community (faculty, staff, students, parents) are treated with dignity and respect. Participants are admitted to Core Elements Higher Education Resource Center’s programs with the understanding that they will fully participate in the program and activities. The use of cellphones and/or other electronic devices are not allowed during course sessions without permission from the facilitator. For students to maximize their learning experience in the program, attendance is essential. Students with multiple unexcused absences will be removed from the program.
Student Signature:
*
Parent/Guardian Signature:
*
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Core Elements Higher Education Resource Center: Release of Information to Authorized Persons/Organizations
I consent to allow Core Elements Higher Education Resource Center release information regarding the student participant in the Core College Program. This may include name, hometown, high school attended and/or graduated from and information relating to any financial aid awarded during attendance at any higher education institution, major, and program information such as general location or term. I understand that information collected may be used for organizational research purposes. I understand non-consent does not affect my participation in the program. I understand only a summative of this information would be shared publicly (no individual identifiable characteristics would be released). I understand the data will be used to track trends, help determine new program offerings, request grant funding, and so forth. I understand Core Elements Higher Education Resource Center monitors the progress of students who participated in the program to better evaluate the effectiveness of the Core College Program in light of its mission and vision. As part of the monitoring process, aggregated information may be shared that does not include my Personal Information and may otherwise disclose non-identifying information with third parties for analysis, demographic profiling and other purposes. Any aggregated information shared in these contexts will not contain student personal Information. I understand that Core Elements Higher Education Resource Center will take appropriate steps designed to secure and protect the information provided, to keep it confidential, and to prevent others from connecting this data to the participant. To the extent possible, except as set forth in this form, any information that could identify me will be removed or changed before such information is shared with other researchers, organizations, or institutions and before any research results are made public in an aggregated form. Except as set forth in this form, under no circumstances will the participant identity and personal information be revealed by. This authorization will remain in effect until I revoke it, which I may do at any time by contacting Core Elements Higher Education Resource Center.
Student Signature:
*
Parent/Guardian Signature:
*
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Core Elements Higher Education Resource Center: Photo, Video, & Sound Recording Release
By signing this Photo, Video and Sound Recording Release and Consent Form, you are irrevocably giving permission to Core Elements Higher Education Resource Center officers, agents, employees, successors, licensees, and assigns to take and use photographs, video or sound recordings of your child throughout their participation in the Core College Program. This is completely voluntary and up to you. Your consent to the use of the photographs, video and sound recordings and your child’s image, likeness, appearance, and voice is for forever. You will not receive compensation for the use of your child’s image, likeness, appearance, and voice now or in the future. Core Elements Higher Education Resource Center may use the photographs, video and sound recordings containing your child’s image, likeness, appearance and voice in any manner or media, including use on web pages. The photographs, video and sound recordings may be used in whole or in part, alone or with other recordings. The photographs, video and sound recordings may be used for any educational, institutional, scientific or informational purposes whatsoever, but not for any commercial uses. Core Elements Higher Education Resource Center has the right and may allow others outside the organization to copy, edit, alter, retouch, revise and otherwise change the photographs, video and sound recordings at the organization’s discretion. All right, title, and interest in the photographs, video and sound recordings belong solely to Core Elements Higher Education Resource Center. You further give permission to Core Elements Higher Education Resource Center to use your child’s name, biography, and any other personal data, events, or other material in or in connection with any such uses of the photographs, video and sound recordings. I understand and agree to the conditions outlined in this photograph, video and sound recording release and consent form. As the parent or legal guardian of the participant named below and on behalf of my child, I irrevocably give consent to Core Elements Higher Education Resource Center and the organization’s officers, agents, employees, successors, licensees, and assigns forever to make use of my child’s image, likeness, appearance, and voice in photographs, video and sound recordings as described above. I acknowledge that I am fully aware of the contents of this release and am under no disability, duress, or undue influence at the time of my signing of this instrument.
Student Signature:
*
Parent/Guardian Signature:
*
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9th Grade College & Career Readiness Program
$
50.00
This cohort specifically serves the needs of 9th grade scholars ($5 x 9 Sessions + $5 Administration Fee = $50). This cost is not inclusive of additional non-mandatory activity fees (college tours, year in banquet, etc.). *The fee is non-refundable*
10th Grade College & Career Readiness Program
$
50.00
This cohort specifically serves the needs of 10th grade scholars ($5 x 9 Sessions + $5 Administration Fee = $50). This cost is not inclusive of additional non-mandatory activity fees (college tours, year in banquet, etc.). *The fee is non-refundable*
11th Grade College & Career Readiness Program
$
95.00
This cohort specifically serves the needs of 11th grade scholars ($5 x 18 Sessions + $5 Administration Fee =$95). This cost is not inclusive of additional non-mandatory activity fees (college tours, year in banquet, etc.) *The fee is non-refundable*
12th Grade College & Career Readiness Program
$
140.00
This cohort serves the needs of 12th grade scholars ($5 x 27 Sessions + $5 Administration Fee =$140). This cost is not inclusive of additional non-mandatory activity fees (college tours, year in banquet, etc.). *The fee is non-refundable*
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