Applicant’s Name: _____________________

SHENANDOAH VALLEY GOVERNOR’S SCHOOL

STEM Program Application Checklist for Fall 2014

The following items are your responsibility to complete/accomplish for your application to SVGS. This checklist is to aid you in making sure nothing is omitted. All materials must be returned to your guidance counselor by his or her deadline, including teacher recommendations and test scores, so plan accordingly.

ALL FORMS MUST BE TYPED!!!!

To Return to Counselors: _____ Completed Application Form (DUE TBA by your school counseling department) _____ Counselor Recommendation Form (with your name on it!) To distribute to a teacher who can provide you an honest and excellent recommendation: _____ Math Teacher Recommendation _____ Science Teacher Recommendation To Schedule Prior to the Deadline: _____ Science Skills Assessment. Check with your counselor for your high school’s testing date. _____ PSAT Test

You may substitute the SAT percent scores if you are unable to take the PSAT on the dates it is given. However, your scores are due to your counselor by his/her specified date.

Please be aware that test scores are FINAL as of this due date! (You may not take them later in the year to submit improved scores for this application process.)

DO NOT RETURN THIS PAGE WITH APPLICATION.

The Augusta County School Board does not discriminate on the basis of race, color, national origin, religion, age, disability, or gender in its programs and activities and provides equal access to the Boy Scouts and other designated youth groups. The following persons have been designated to handle inquires regarding non-discrimination policies:

The following individuals have been designated to handle all inquiries that pertain to the non-discrimination policies.

Title IX Coordinator Eric W. Bond, Ed.D 18 Government Center Ln. Verona, VA 24482 (540) 245-5100

Section 504 Coordinator George Earhart 18 Government Center Ln.

Verona, VA 244829 (540) 245-5100

SHENANDOAH VALLEY GOVERNOR’S SCHOOL

Application Form for the Science, Technology, Engineering and Mathematics Program

To be completed by applicant Each applicant must:

Complete the application and activities sheet by typing in the spaces provided. Provide recommendation forms to one math and one science teacher. Have taken the PSAT test in October, 2013, or SAT by January, 2014. Complete the STEM skills assessment at SVGS (check with counselor for your high school’s date). Priority is given to students enrolled in Augusta County, Staunton or Waynesboro Public Schools.

Student's Full Legal Name: _____________________________________________

Preferred Nickname: ________________ DOB: __/__/__ Gender:____________

I am currently a SOPHOMORE JUNIOR at High School:______________________ Indicate appropriate grade level

Address: _____________________________________________________ _____________________________________________________ Student Email: (Please type!)_________________________________ Parent(s) Information: Mother Dr. / Ms. / Mrs.________________________________________

Please circle appropriate title First Name Last Name

Father Dr. / Mr._____________________________________________ Please circle appropriate title First Name Last Name

Phone (home): ______________ Other phone: ___________________ Parent Email: (Please type!)_________________________________

To be completed by applicant: I apply for admission to SVGS for the Fall 2012 school year. I waive the right to view recommendations

provided by teachers and counselors as part of this application. I agree to participate in the mandatory Summer Orientation program tentatively scheduled during the week prior to the beginning of school in August, 2014. I agree to complete a research or engineering project and to present it at the SVGS research symposium, VJAS and/or other appropriate venue as required by my instructor. I agree to complete a senior leadership and service project as part of my program completion requirements.

________________________________ _______________ Signature Date

To be completed by parent or legal guardian: I grant my son or daughter permission to apply to SVGS for the Fall 2014 school year. I waive the right to view recommendations provided by teachers and counselors as part of this application. I agree to provide or arrange for transportation for my child. I agree to have my child participate in the mandatory Summer Orientation program tentatively scheduled for the week prior to the beginning of school. I agree to have my child complete a research or engineering project and to present it at the SVGS research symposium, VJAS and/or other appropriate venue as required by the instructor and complete a senior leadership and service project as part of his/her program completion requirements. __________________________________ _______________ Signature Date

Significant Activities (To be completed by applicant)

Points Name: _________________________________ (out of 50) Explain, in 100 TYPED words or fewer each in the spaces provided, the two most important and/or beneficial school-related activities in which you have engaged since entering high school.

Year Extra- or Co-curricular Clubs/Activities

Your Role

Why is this significant in your life? 2009-2010

Science Club Vice President I have always loved science but sometimes had a hard time understanding how science could help people with their problems. Being in this club has enabled me to apply what I’ve learned in biology to an environmental clean-up project and tutor younger students at the elementary school in the afternoons. I’ve discovered I love both science and teaching! It has also helped me make new friends who share my academic interest.

Explain, in 100 TYPED words or fewer each in the spaces provided, the two most important and/or beneficial sports and/or arts activities in which you have engaged since entering high school. If you have not participated in athletics or the arts, please use the space to explain why you have not.

Year Sports or Arts Your Role Why is this significant in your life?

Explain, in 100 TYPED words or fewer each in the spaces provided, ANY two other important and/or beneficial activities, community organizations, church organizations, and/or work experiences in which you have engaged since entering high school.

Year Activity, Events and/or

Experiences

Your Role

Why is this significant in your life?

STEM Program Application for 2014-15 Year Shenandoah Valley Governor’s School

Math Teacher Recommendation Form

Student’s name: _______________________________________________________

Teacher’s name and signature:___________________________________________

Subject(s) you taught student: ___________________________________________

Grade(s) in which you taught course(s) above: _____________________________

Directions: Circle one number in every category. Please do not mark between or circle two

numbers. Doing so hurts the student involved. Total your ratings. Return completed forms ASAP directly to Guidance .

Use the following rating scale, comparing the applicant to other students THIS year or semester:

0 = Below Average 2 = Average 4 = Very good 6 = Outstanding Below Outstanding Average

1. Academic Ability High aptitude and potential for success in advanced mathematics, easily learns new material

2. Academic Interest Intense interest in learning, very curious, eager to learn new concepts

3. Motivation and Persistence Shows initiative, welcomes instruction, self-confident, motivated by challenge

4. Quality of Work Complete, thorough, strives for excellence

5. Logical and Analytical Skills Applies knowledge, reasons through problems, makes intuitive leaps, finds unique patterns or perspectives

6. Class Preparation Consistently does assigned readings and homework, is prepared to contribute

7. Work Habits and Time Management Disciplined, turns in work on time, meets obligations

8. Class Participation Contributes positively to discussions and activities, shares ideas

9. Communication with Peers Demonstrates sensitivity, respects others and opposing ideas, may demonstrate leadership in groups

10. Dependability Consistent, supports others

0 2 4 6

0 2 4 6

0 2 4 6

0 2 4 6

0 2 4 6

0 2 4 6

0 2 4 6 0 2 4 6

0 2 4 6

0 2 4 6

Total Score: (out of 60 possible points)

STEM Program Application for 2014-15 Year Shenandoah Valley Governor’s School

Science Teacher Recommendation Form

Student’s name: ________________________________________________

Teacher’s name and signature: ____________________________________

Subject(s) you taught student: ____________________________________

Grade(s) in which you taught course(s) above: _______________________

Directions: Circle one number in every category. Please do not mark between or circle two numbers. Doing

so hurts the student involved. Total your ratings. Return completed forms ASAP directly to Guidance .

Use the following rating scale, comparing the applicant to other students THIS year or semester: 0 = Below Average 2 = Average 4 = Very good 6 = Outstanding

Below Outstanding Average

1. Academic Ability High aptitude and potential for success in science, easily learns new material

2. Academic Interest Intense interest in learning, very curious, eager to learn new concepts

3. Motivation and Persistence Shows initiative, welcomes instruction, self-confident, motivated by challenge

4. Quality of Work Complete, thorough, strives for excellence

5. Logical and Analytical Skills Applies knowledge, reasons through problems, makes intuitive leaps, finds unique patterns or perspectives

6. Class Preparation Consistently does assigned readings and homework, is prepared to contribute

7. Work Habits and Time Management Disciplined, turns in work on time, meets obligations

8. Class Participation Contributes positively to discussions and activities, shares ideas

9. Communication with Peers Demonstrates sensitivity, respects others and opposing ideas, may demonstrate leadership in groups

10. Dependability Consistent, supports others

0 2 4 6

0 2 4 6

0 2 4 6

0 2 4 6

0 2 4 6

0 2 4 6

0 2 4 6

0 2 4 6

0 2 4 6

0 2 4 6

Total Score: (out of 60 possible points)

Applicant’s Name____________________________

STEM Program Counselor Check List (for counselor use only)

Check list can be used to mark off items that have been submitted. Please put the packets together, in the order below, which will aid the selection committee as they review applications. (This form does not need to be turned in with student application packet.)

_____ Scoring Sheet (with scores and totals for each section, please) _____ Application Form (Review for completeness) _____ Activities Sheet _____ Math Teacher Recommendation (Review for completeness) _____ Science Teacher Recommendation (Review for completeness) _____ Counselor Recommendation and School Recommendation _____ PSAT score report (on transcript or separate attachment) _____ SVGS Science skills assessment (score from SVGS) _____ Transcript _____ Copy of spring semester schedule _____ Most recent report card

Please arrange the application packet in the order listed.

Please do not send this page with application.

STEM Program Application for 2014 - 2015 Year

Shenandoah Valley Governor's School Counselor Recommendation Form

Student's Name: _______________________________________________

How long have you known student? _______________________________

Directions: Use rating scale categories below. Mark one circle in every category. Please DO NOT mark between or circle two numbers. Not

following this instruction hurts students in the application process. TOTAL YOUR RATINGS

The following ratings apply: 1 = Below Average 2 (or 4) = Average 3 (or 6) = Excellent (top 10% this year) 4 (or 8) = Outstanding (top few this year)

Below Out- Average Standing 1. Motivation and Persistence .....................................................1 4 6 8

Curious, self-starter, shows initiative, accepts criticism 2. Work Habits/Time Management .............................................1 4 6 8

Disciplined, does not procrastinate 3. Self-Esteem ...............................................................................1 2 3 4

Positive self-image, self-confidence 4. Communication with Peers ......................................................1 2 3 4

Demonstrates sensitivity, respect for others and opposing viewpoints, shares ideas

5. Academic Ability .......................................................................1 2 3 4 High aptitude and potential for success

6. Academic Interest ....................................................................1 2 3 4 Intense interest in and appreciation for learning new things

7. Dependability ...........................................................................1 4 6 8 Consistent, disciplined, supports others

TOTAL SCORE (Out of 40)

Counselor Signature: _________________________________ Date: __________

STEM Program Application for 2014 - 2015 Year

Shenandoah Valley Governor's School School Recommendation Form

Student's Name: _______________________________________________

Overall Recommendation After consideration of the student’s qualifications, we make the following recommendation to the Selection Committee:

_____ Highly recommended without reservation (60 points) _____ Recommended (45 points) _____ Recommended with reservation (30 points) _____ Not recommended (0 points)

Principal’s Review

I have reviewed the application for the above named student and concur with the findings and recommendations. I certify that this student is in good standing with regard to discipline and attendance. Signature: _________________________________ Date: __________

STEM Program Application for 2014 - 2015 Year

SVGS Selection Form Fall 2014 Year

Applicant’s Name: Current Grade Level:____ Experience/Training/Activities Points (out of 50) Recommendations:

Math Teacher (out of 60) __________

Science Teacher (out of 60) __________

Counselor (out of 40) __________

School Recommendation (out of 60) __________

SUBTOTAL (out of 220) PSAT Scores: Test Date: ________

Verbal Percentile __________ x 0.9 = __________

Math Percentile __________ x 2.0 = __________

Writing Percentile __________ x 0.9 = __________

SVGS Science Skills score: __________ = __________ SUBTOTAL (out of 430) Current GPA: (circle appropriate) weighted unweighted

*Please make “weighted” if student has taken DE or AP classes calculated in the reported GPA. Please mark “unweighted” if the student does not have weighted grades calculated in the reported GPA.

GPA: __________ x 40 = __________ Strength of Academic Program (Enter the appropriate number from below): __________

Almost always most challenging courses (with one or two exceptions - available honors, AP or dual-enrollment courses) 50 points

Usually most challenging courses (at least half of available) 40 points

Few of the most challenging courses (one or two) 30 points

SUBTOTAL (out of 210)

TOTAL SCORE (out of 910))