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10901 Little Patuxent Parkway Columbia, MD 20144-3197 443-518-1000www.howardcc.edu

Dear Parents and Students:

Please submit this application as soon as possible. The deadline for the applications will be May 15, 2021. No incomplete applications will be considered. The tuition fee of $700.00 (inside Howard County) or $710.00 (instate/outside Howard County) for the Project Access Summer Institute will be charged after the student is accepted to the program. Scholarship money will be available for students in financial need.

The dates for the 2021 Summer Institute will be from July 6 – July 30, 2021. Classes will meet from 9:00 A.M. – 3:00 P.M., Monday through Friday, with the exception of Friday, July 30th. On this day, there will be no daytime classes. Instead, there will be a Student Awards Ceremony and a Banquet for students and families. This event is considered to be an important part of the program and the student is expected to attend.

If you have any additional questions, please contact the Project Access office at:

Telephone: 443-518-4625 E-mail: projectaccess@howardcc.edu

Please send/email application to: Dianne Nagle, Associate Director Project Access Howard Community College RCF Student Services Hall, #302 10901 Little Patuxent Parkway Columbia, MD 21044 projectaccess@howardcc.edu

Sincerely,

Dianne Nagle Associate Director, Project Access Howard Community College dnagle@howardcc.edu

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Repeat Student to Project Access (Please check the box)

PROJECT ACCESS APPLICATION

PLEASE PRINT STUDENT INFORMATION

Date

Name

Birth Date Age M F

Address

City State Zip Code

Home Phone Number Cell Phone Number(Student)

E-Mail Address (Student)

High School Grade

School Counselor

High School Address

High School Phone Number

Is this student pursuing a high school diploma? Yes or No

Date of Most Recent IEP Team Meeting or 504 Meeting

In order to participate in this program, are there any accommodations you would need?

PERSONAL INTERESTS

Out-of-school hobbies, interests, activities

What do you plan to do after high school graduation?

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Please list the Area of Study or Major that you would like to explore in college or as a career.

1st Choice

2nd Choice

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CONTACT INFORMATION

Parent or Legal Guardian

Name Relationship to student

Occupation:

Work Phone Number: Cell Phone Number

E-Mail Address:

Parent or Legal Guardian

Name: Relationship to student

Occupation

Work Phone Number: Cell Phone Number

E-Mail Address:

*Additional Contact (Optional)*

Alternate contact that may be reached.

Name: Relationship to student

Cell Phone Number Home/Work Phone Number

TRANSPORTATION Would you need transportation in order to participate in this program? yes no If yes, please list a location in Howard County (church, school, shopping center, etc.) that may be used as a transportation stop.

I hereby certify that the information provided by me in this application is true to the best of my knowledge.

Student Signature Date

Parent/Guardian Signature Date

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PROJECT ACCESS APPLICATION

HEALTH HISTORY

Student’s Name Date

1. List all known ALLERGIES including food, medicines, insect stings, pollens, dust, etc. Ifnone write “NONE.”

2. ILLNESSES: Do you have or have you ever had any of the following?

Illness Yes No Asthma Back/Joint Problems Diabetes Emotional Problems Hearing Problems Heart Disease Kidney Disease

Seizures Vision Problems Other

3. If you answered “yes” to any of the illnesses, please explain:

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HOWARD COMMUNITY COLLEGE

PROJECT ACCESS

STUDENT WRITING SAMPLE

(This can be typed or written, as long as it is student generated.)

Please write a one hundred word essay that answers the following questions:

A) What do you think you will gain from being a participant in Project Access?B) How do you hope to put this information to use?

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The tuition fee for Project Access is currently $700.00 (inside Howard County) and $710.00(instate/out of county) and $720.00 (outside Maryland) .

An attempt will be made to provide funds for all students who need them in order to attend the Project Access Summer Institute. Funds will be awarded based on Howard Community College’s guidelines for financial aid. If you are interested in obtaining such a grant, please complete the following form:

Project Access Summer Institute Grant Application

Name

Address

Telephone (H) Telephone (c)

Telephone (W

Household Annual Income Household Size

Annual Expenses Related to Disability Not Covered by Insurance

Statement of Understanding

By signing this application, I agree, if asked, to provide information that will verify the accuracy of my completed form. This information may include a copy of my federal or state income tax form.

I declare that the foregoing is true and correct, as is all the information on this application and its supporting documents.

Parent/Guardian Signature Date

Student’s Signature Date

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HOWARD COMMUNITY COLLEGE

PROJECT ACCESS

STUDENT EVALUATION

(To be completed by a Counselor, Teacher, or Psychologist)

Please remit this confidential evaluation directly to Project Access either through sealed envelope or through email.

Student’s Name Date

Student Evaluator Title

High School

Project Access is a transitional program for high school students with disabilities who have the potential to pursue postsecondary education. The focus of Project Access is for students pursuing a high school diploma, not a certificate of attendance.

The primary goals of Project Access are to provide students with experiences that will improve their academic and transitional/college success skills and enhance their abilities to matriculate successfully into postsecondary educational opportunities.

Please respond to each of the following as they are appropriate for this student:

1. Academic Potential Excellent Good Fair

2. Motivation Excellent Good Fair

3. Attendance Excellent Good Fair

4. Punctuality Excellent Good Fair

5. Disciplinary SituationHas this student been involved in any disciplinary actions? If yes, pleasecomment.

6. Is this student on a high school diploma track? Yes No

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7. In your opinion, do you feel that this student will be ready to transition to a post-secondary institute after receiving their high school diploma? Yes NoIf no, please give brief explanation.

8. Are there any concerns that may be necessary to address in order to make asuccessful transition to college? Yes No If yes, please explain.

9. List strengths that you believe a Project Access instructor should know about thisstudent.

10. Do you recommend this student for Project Access? Yes No

Signature

Title

Telephone Number

Please send/email to:

Dianne Nagle, Associate Director Project Access Howard Community College RCF Student Services Hall, #302 10901 Little Patuxent Parkway Columbia, MD 21044 projectaccess@howardcc.edu

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HOWARD COMMUNITY COLLEGE

PROJECT ACCESS

Dear Parents and Students:

The personal information that you provide to Project Access is protected by the Privacy Act. No one may see this information unless they work for Project Access, or are specifically authorized to see the information. The information is necessary to determine participation eligibility.

Great care is taken to ensure that the personal information collected on Project Access students is kept confidential. Information or records relating to individual Project Access students shall not be disclosed to any person, group, or organization without the express permission of the Project Access Director.

Please sign and return the Release of Records form to Project Access at Howard Community College along with the rest of the application. Project Access will obtain the IEP/504 plan and other relevant documentation from the high schools when needed.

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HOWARD COMMUNITY COLLEGE

PROJECT ACCESS

RELEASE OF RECORDS

Dear Parents and Students:

Please sign and return the release of Records form directly to Project Access at Howard Community College. We will send for the relevant documentation when necessary.

Re: Student

Grade High School

I hereby authorize you to release the transcript, I.E.P/504 plan, disability diagnostic information and any other pertinent materials that may be needed regarding educational status. Similar materials may be required over a period of three years in order to demonstrate any improvement that occurred as a result of attending the Project Access Summer Institute. Information received shall remain in strict confidence and be used by professional staff only.

I hereby request that these materials be sent to:

Dianne Nagle Project Access

RCF Student Services Hall #302 Howard Community College

10901 Little Patuxent Parkway Columbia, MD 21044

Student’s Signature Date

Parent’s or Guardian’s Signature Date

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WAIVER OF RESPONSIBILITY Project Access Summer Institute

In connection with my participation in the Project Access Summer Institute college visit

activity on July 9th, 16th, and 23rd, 2021, sponsored by Howard Community College (HCC),

I understand that there are certain risks inherent in the nature of this activity. I waive all

claims, costs, liabilities, expenses, and judgments against HCC and Howard County

government and release HCC and its trustees, officers, agents, representatives, and employees

and Howard County government from all claims, costs, liabilities, and expenses, and

judgments arising out of my participation in the college visit activity. I further agree to abide

by all rules and regulations as dictated by the staff of Project Access.

Parent/Guardian Signature

Student Signature

Date