PROGRAM APPLICATION
Applications will be accepted beginning September 1st for the following school year. This application form and all supporting documents must be received by April 1st to be given consideration for that school year. Decisions are typically made in May. All information provided is confidential. IF YOU NEED TO CONTINUE THE APPLICATION AT A LATER TIME, PLEASE CLICK ON THE SAVE BUTTON. YOU DO NOT HAVE TO CREATE A PASSWORD. YOU DO NEED TO PROVIDE AN EMAIL AND A LINK TO THE SAVED FORM WILL BE SENT TO YOU.
Any questions, please contact Katie: (774) 400-7954; kferguson@newbedfordstarkids.org
ADDITIONAL INFORMATION: Your application will NOT be considered without all of the following: 1. Program Application 2. Documentation of Incarceration OR Substance Abuse 3. Teacher Recommendation (can be sent in by teacher/school or parent) 4. Counselor Recommendation (if applicable) 5. Grades (copy of latest report card). 6. Financial Information (two of these: 1040, W-2, State Benefit Form, Pay Stub) 7. A current photo of your child
Admissions Policy: New Bedford Star Kids Scholarship Program has an admissions criteria that must be satisfied in order for an applicant to be admitted to the program. New Bedford Star Kids Scholarship Program does not deny acceptance into the program based on an applicant’s race, color, religious creed, national origin, sex, age, criminal record, or disability including blindness or deafness. Any questions about qualifications for said program shall be addressed to the executive director.
PART A: Student Information
Student's Name:
*
First Name
Last Name
Student's Date of Birth:
Student's Gender:
Male
Female
Grade at time of Application:
Grade applying for:
Student's Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Email (best email for contact):
*
example@example.com
Student's Race/Ethnicity:
Caucasian
African American
Native American
Hispanic
Bi-Racial
Multi-Racial
Other
Upload a current photo of the applicant.
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PART B: Parent/Guardian Information
Custodial Parent/Guardian 1:
First Name
Last Name
Custodial Parent/Guardian 2: (if applicable)
First Name
Last Name
Non-Custodial Parent/Guardian 1: (if applicable)
First Name
Last Name
Parents/Guardians Telephone Number (Preferred number to call):
Please enter a valid phone number.
Additional Parents/Guardians Telephone Number:
Please enter a valid phone number.
Parent's/Guardian's Email Address:
example@example.com
Additional Parents/Guardians Email Addresses (if needed):
example@example.com
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Part C: School/Educational Information
Student's Name:
First Name
Last Name
Current School:
School Contact:
School Contact's Phone Number:
Does the Student have any physical or emotional conditions that Star Kids should be aware of?
Has the student ever had any psychological or educational evaluation?
YES
NO
If YES, date of testing?
Family Case Manager/Counselors (If available):
Phone Number:
Please enter a valid phone number.
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Part D: Family Information
Family History of Incarceration
Please provide documentation of incarceration.(For example intake/release records, court documents.) If there is no history of incarceration, skip to the next section.
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Please provide a brief summary of the impact that incarceration of family members has had on the applying child:
Is the child's biological mother currently incarcerated?
Yes
No
Unknown
Was the child's biological mother formerly incarcerated?
Yes
No
Unknown
Is the child's biological father currently incarcerated?
Yes
No
Unknown
Was the child's biological father formerly incarcerated?
Yes
No
Unknown
If YES to any of the above questions regarding the child's parents, please provide the details:
Dates of EACH incarceration and how long served: Please be specific.
What were the convictions? Please be specific for each.
Is either parent on parole? If so, who?
Did either parent have trouble with the law earlier in life? If yes, at what age and for what?
Was either parent a ward of the state as a child/teen?
Does any family member have a history of incarceration?
Yes
No
Unknown
If yes to the above question, please explain the relationship to the applicant.
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FAMILY HISTORY OF SUBSTANCE ABUSE
Please provide documentation of substance abuse (for example, documentation from a substance abuse treatment program, a social worker, counselor or approved professional). If there is no history of substance abuse, skip to the next section.
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Please provide a brief summary of the impact that substance abuse by family members has had on the applicant:
Does the child's biological mother have substance abuse issues now?
Yes
No
Unknown
Has the child's biological mother had substance abuse issues?
Yes
No
Unknown
Does the child's biological father have substance abuse issues now?
Yes
No
Unknown
Has the child's biological father had substance abuse issues?
Yes
No
Unknown
If YES to any of the above regarding the child's parents, please provide details:
What substances were abused and for how long? Please be specific.
Has the person(s) been in a residential or out-patient treatment program?
Yes: both parents
Yes: Mother
Yes: Father
Neither
Unknown
Name(s) of program(s), location(s) and dates of programs:
Does any other family member have substance abuse issues now?
Yes
No
If YES, please explain the relationship to the applicant.
Has your family ever had DCF involement?
Yes
No
If YES, please explain.
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What schools are you applying to?
Family Members
How did you hear about New Bedford Star Kids Scholarship Program?
Is there anything else we should know about the applicant?
Parent/Guardian Name (PRINT):
Parent/Guardian Signature
Date
-
Month
-
Day
Year
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AUTHORIZATION FOR THE RELEASE OF SCHOOL RECORDS
Student's Name:
First Name
Last Name
Student's Date of Birth:
Student's Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student's School:
Student's Grade:
Information Requested:
•Report Cards, progress reports and teacher/advisor/coach comments (as they are issued, by trimester or semester) •Test Scores •Standardized test results •Results of child and/or family assessments •Disciplinary records •IEP's •Speech/Language, Psychological, Behavioral and/or Psychological Evaluations
In consideration of my child's participation in the New Bedford Star Kids Scholarship Program, I hereby give my permission for the above information to be sent by my child's school to the New Bedford Star Kids Scholarship Program for as long as my child participates in the program.
I understand that this information shall not be released by the school to any other recipient without my written permission. I also understand that I may withdraw this consent at any time in the future.
Print Name of Parent/Guardian
Signature of Parent/Guardian
Date
Upload the applicant's most recent report card.
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PARENTAL AUTHORIZATION TO RELEASE INFORMATION
Student's Name:
First Name
Last Name
Student's Date of Birth:
School:
Grade:
In consideration of my child's participation in the New Bedford Star Kids Scholarship Program, I hereby agree that any information pertaining to the educational, financial and/or personal well-being of my child may be shared by my child's school directly with the New Bedford Star Kids staff, my child's mentor and my child's scholarship sponsor. This includes, but is not limited to:
•Report Cards, progress reports and teacher/advisor/coach comments (as they are issued, by trimester or semester) •Test Scores •Standardized test results •Results of child and/or family assessments •Disciplinary records •IEP's •Speech/Language, Psychological, Behavioral and/or Psychological Evaluations
I understand that New Bedford Star Kids may contact my child's school or another agency directly to obtain this information as needed. I also agree to allow Star Kids to share their information about my child with any agency helping my child.
This release shall be valid for the duration of my child's participation in the New Bedford Star Kids Scholarship Program.
Print Name of Parent/Guardian:
Signature of Parent/Guardian
Date:
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PHOTO CONSENT AND RELEASE
Student's Name:
First Name
Last Name
Student's Date of Birth:
Current Grade:
I agree to allow New Bedford Star Kids Scholarship Program and it's representatives to take my child's picture and/or video. Said picture and/or video may be taken at school or at any of the New Bedford Star Kids' events. I also agree that my child's images may be used in any New Bedford Star Kids' literature including websites, social media, annual report, annual appeal, local newspapers and magazines as well as any literature that promotes the mission of the New Bedford Star Kids' Scholarship Program. I also agree that any picture and/or video of my child may be shared with his/her sponsor.
I understand that this release shall be valid for the duration of my child's participation in the New Bedford Star Kids Scholarship Program. I also understand that I may withdraw my consent at any time.
Name of Parent/Guardian:
Signature of Parent/Guardian
Date:
***If you wish to opt out of having your child's image used by the New Bedford Star Kids Scholarship Program (except to be shared with child's sponsor), please sign below:
Signature (IF you do not want your child's image used by New Bedford Star Kids Scholarship Program-except to be shared with child's sponsor)
Date:
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TEACHER RECOMMENDATION
Please notify your child’s teacher to visit our website and complete the teacher’s recommendation form. YOUR APPLICATION IS NOT COMPLETE UNTIL WE RECEIVE THE TEACHER’S RECOMMENDATION FORM. The form is located under the “Application” section.
Student's Name:
First Name
Last Name
Student's Date of Birth:
Current School:
Current Grade:
Current Teacher's Name:
Current Teacher's Email Address:
example@example.com
Counselor/Social Worker Recommendation
Please notify your family/child's counselor or social worker to visit our website and complete the counselor/social worker’s recommendation form. The form is located under the “Application” section. If there is no counselor/social worker, input N/A and move to the next section.
Counselor's Name:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Counselor/Social Worker's Email:
example@example.com
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Please upload photos of your financial information. Two of these: 1040, W2, State Benefit Form, Pay Stubs)
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Documents needed to complete the application
An application is not considered complete until we have all the documents listed below.
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