LPP Application & Student Questionnaire
This New York State funded program is designed to provide services to help improve student's academic performance and potential for success. This form must be completed by each student's parent or guardian for the enrollment process to be completed.
Student Information
Student Preferred Email
*
example@example.com
Name
*
First Name
Middle Initial
Last Name
Who referred you to SU LPP?
*
Ms. Michelle Weber
Ms. Haleh Tabesh
Mr. Maysam Seraji
Ms. Ntsoaki Cappa
SCSD School Counselor
Other
Date of Birth
*
-
Month
-
Day
Year
Date
Student's Preferred Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name of School
*
Please Select
Corcoran
PSLA
Clary
Roberts
Brighton Academy
Grade Level
*
Please Select
6
7
8
9
10
11
12
Ethnicity
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Two or More Races
Gender
*
Please Select
Female
Male
Non-binary
Prefer not to respond
Are you currently enrolled in Onondaga Community College (OCC’s) LPP or Le Moyne’s LPP?
*
Yes
No
Don't Know
Student (adult) T-shirt size
*
XS
S
M
L
XL
2XL
Parent/Guardian Information
Parent/Guardian's First and Last Name
*
First and Last Name
Parent/Guardian Preferred Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian's Email
*
example@example.com
Image/Media Request
I 𝗗𝗢 𝗡𝗢𝗧 grant permission for my child’s photograph (whether still, motion, or television),writings, and/or recordings of his/her voice taken during the course of the program to be used in LPP publications, website, and promotions.
Emergency Contact Information
First and Last Name of Emergency Contact
*
First and Last Name
Relationship to Student
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Program Agreement
By completing this form, I authorize Liberty Partnerships Program personnel to obtain and review my child’s school records, and I understand that records will be used in planning appropriate academic support and counseling services (academic, college, career and personal) for my son/daughter. I understand that all of the information will be kept confidential to the extent required by law. I authorize the disclosure of educational information between the Liberty Partnership Program (LPP) and the Syracuse City School district in accordance with the Family Educational Rights and Privacy Act (FERPA).
Parent/Guardian Signature
*
Student Signature
*
Date
-
Month
-
Day
Year
Date
Back
Next
Student Questionnaire (Personal Learning Plan PLP)
The following sections will help us to get to know you better as we welcome you to the SU LPP family.
Select the area(s) you would like LPP to support you with:
*
Academic
Social Emotional
Job/Career
College Readiness
Academic Support
What classes/subject(s) do you need help in?
*
Math
Science
English
History
None at this time
Other
What do you need to be a more successful student?
*
Time Management / Procrastination
Improving Study Habits
Understanding Academic Content
None at this time
Other
Social Emotional Support
What helpful habits have you developed/used?
*
What harmful habits have you developed/used?
*
Are you taking care of yourself (sleep, healthy diet, exercise, etc.)?
*
Pretty well
Could use some help
Prefer not to answer
Select all resiliency skills you would like to improve on:
*
Confidence
Connections (for example connection with peers, family, teachers...)
Stress
Overall Well-Being
Motivation
Prefer not to answer
Job/Career Support
What can LPP help you with:
*
Cover Letter
Resume Building
Job Application
Interview Skills
Career Exploration
Job/Internship/Volunteer Placement
None at this time
Other
College Readiness
What can LPP help you with:
*
Financial Aid
College Search
College Application Process
None at this time
Other
Continue
Continue
Should be Empty: