SCARSDALE MIDDLE
SCHOOL
CHOICE
APPLICATION
Thank you for your interest in the CHOICE program. Enclosed you will
find:
☐
Application form. Please be sure to attach your written response.
☐
Student Self-Evaluation form
☐ 2 Teacher Feedback forms. Please select two teachers to
complete these. The teachers will return them directly to the CHOICE
program, not to the student.
Applications should be completed and returned to Mr. McDermott’s
office by Monday, May 8, 2017
SCARSDALE MIDDLE SCHOOL
APPLICATION FOR CHOICE
Applications must be returned to Mr. McDermott’s office no later than
Monday, May 8, 2017
PLEASE PRINT
Student Name ________________________________________________
Current House _______________________________________________
Please complete the following and attach a written response for part one to this
application.
1. Describe why you want be part of the CHOICE program. Be as
specific as possible.
2. Please complete the Student Self-Evaluation form.
3. Please indicate the two teachers you will be asking to complete
Teacher Feedback Forms:
______________________
____________________________
Student Signature
Date
__________________________
_______________________
Parent Signature
Date
By signing, you understand that the CHOICE program requires a two-year commitment on the
part of the student. All applications will be reviewed with Administration, House Counselors,
and CHOICE staff to determine if placement is appropriate. Teacher feedback forms are
confidential communications and will not become part of a child’s permanent record.
Parents/students waive all rights to access these feedback forms.
CHOICE APPLICATION
STUDENT SELF-EVALUATION
Please assess yourself based upon the following categories:
1 indicates improvement is needed, 3 is satisfactory, 5 is excellent
1. Academic achievement
1
2
3
4
5
2. Work habits
1
2
3
4
5
3. Emotional maturity
1
2
3
4
5
4. Organizational skills
1
2
3
4
5
5. Reading comprehension
1
2
3
4
5
6. Ability to advocate for yourself
1
2
3
4
5
7. Ability to engage effectively in group activities 1
2
3
4
5
8. Ability to think flexibly and take educational risks
Please include any other information you feel is relevant.
1
2
3
4
5
CHOICE APPLICATION
TEACHER FEEDBACK FORM
Dear 6th grade teacher,
_________________________________ has applied to the CHOICE program
for the 2017-2018 school year. We are trying to gather as much information as
possible about this student and your input is greatly appreciated. Please
complete the following form and return to Cindy Parrott’s mailbox by May 12.
Thank you for your time and consideration.
Please assess the student based upon the following categories with 5 being the
highest possible score:
1. Academic potential
1
2
3
4
5
2. Work habits
1
2
3
4
5
3. Emotional maturity
1
2
3
4
5
4. Organizational skills
1
2
3
4
5
5. Reading comprehension
1
2
3
4
5
1
2
6. Ability to advocate for themselves
3
4
5
7. Ability to appropriately engage in group activities
1
2
3
4
5
8. Ability to think flexibly and take educational risks
1
2
3
4
5
Please include any other information you feel is relevant.
Information on this form is confidential and will not be shared with the student or parent, nor will it
become part of a student’s permanent record.
CHOICE APPLICATION
TEACHER FEEDBACK FORM
Dear 6th grade teacher,
_________________________________ has applied to the CHOICE program
for the 2017-2018 school year. We are trying to gather as much information as
possible about this student and your input is greatly appreciated. Please
complete the following form and return to Cindy Parrott’s mailbox by May 12.
Thank you for your time and consideration.
Please assess the student based upon the following categories with 5 being the
highest possible score:
1. Academic potential
1
2
3
4
5
2. Work habits
1
2
3
4
5
3. Emotional maturity
1
2
3
4
5
4. Organizational skills
1
2
3
4
5
5. Reading comprehension
1
2
3
4
5
1
2
6. Ability to advocate for themselves
3
4
5
7. Ability to appropriately engage in group activities
1
2
3
4
5
8. Ability to think flexibly and take educational risks
1
2
3
4
5
Please include any other information you feel is relevant
Information on this form is confidential and will not be shared with the student or parent, nor will it
become part of a student’s permanent record.