Student Information (Only 1 student per application)

Student’s School ID #/Lunch #

Student Name (Last, First, Middle Initial)

Citizenship

- U.S. Other

If you selected "Other", please specify your Citizenship

Gender

- Male Female

Date of Birth

Age

Student Email

Name of School

Grade Level

Ethnic Group (Optional)

- Black or African-American Asian Caucasian Hispanic/Latino of any race Native-American Multi-Ethnic/Non-Hispanic

If you selected "Multi-Ethnic/Non-Hispanic", please specify your Ethnic group

Do you plan to attend

- College Technology Center Other

If you selected "Other", please specify

What was your last semester G.P.A.?

- 4.0 and above 3.0 - 3.9 2.0 - 2.9 1.0 - 1.9 Below 0.9

Home Address (House number & Street, City, State, Zipcode)

Home Phone Number

Best Parent Phone Number

Student Cell Phone Number

How did you learn about OPEN DOORS?

- Enrollment Table Newspaper Parents In-class Presentation Teacher Counselor Sibling Other Student

OPEN DOORS - STUDENT CONTRACT: I agree to maintain a minimum of cumulative weighted 2.50 GPA. New applicants that are below a 2.50 GPA may request reconsideration for special circumstances. If accepted will be placed on academic probation. I agree to contact my OPEN DOORS advisor if there is a change in my class schedule, my home address or phone number, and/or if my family plans to move from Lawton. I agree to seek help with academic or personal problems if needed. I agree to notify my OPEN DOORS advisor if I am suspended or expelled, or if I have received disciplinary action at school. I agree to attend school regularly and not miss more than ten days of school per semester. I agree to participate in the tutoring sessions as needed and/or recommended by my advisor or teacher. I agree to achieve my goals that have been set up with the help of my OPEN DOORS advisor. I agree to take advantage of special OPEN DOORS activities like college visits, financial aid workshops, and PSAT/ACT/SAT prep workshops. I agree to enroll in a post-secondary educational institution upon graduation from high school. I agree to investigate careers.

Certification of information and acceptance of terms: This is to certify that the information contained in this application is true and correct to the best of my knowledge. Furthermore, I give OPEN DOORS my permission to receive copies of my educational records necessary for participation in the program. Further permission is granted to request information and records from any and all post-secondary institutions and tracking agencies (utilizing my personal identification information) in order to track progress in college. I understand all of my records will be kept in confidence and in accordance with the Privacy Act of 1974. Please choose "Yes" to certify the submitted information and indicate your acceptance of terms.

- Yes No

I understand that if, at any time, an Open Doors student chooses non-traditional, LPS instruction, that student must participate in at least two online services a semester, in order to remain active in the Open Doors program.

- Yes No

Student Signature: Please type your name in the signature block below as acceptance of the terms above.

Parent Information (to be completed by parent or guardian with whom applicant lives)

Parent or Guardian 1: Name, Relationship, Occupation

Parent or Guardian 2: Name, Relationship, Occupation

Please note: All information will be held in strict confidence. We are required by the United States Department of Education to obtain income information from all students receiving OPEN DOORS FREE services. Since you and your student have indicated an interest in receiving our assistance, please complete the following information. Eligibility Information: 1 Family Member (Taxable Income Eligibility Equal to or less than $18, 735). 2 Family Members (Taxable Income Eligibility Equal to or less than $25,365). 3 Family Members (Taxable Income Eligibility Equal to or less than $31,995). 4 Family Members (Taxable Income Eligibility Equal to or less than $38,625). 5 Family Members (Taxable Income Eligibility Equal to or less than $45,255). 6 Family Members (Taxable Income Eligibility Equal to or less than $51,885). 7 Family Members (Taxable Income Eligibility Equal to or less than $58,515). 8 Family Members (Taxable Income Eligibility Equal to or less than $65,145). *For households with more than 8 members, add $6,240 for each additional family member. Based on your TAXABLE INCOME, according to the above information, does your child qualify for our program?

- Yes No

Is your son/daughter a part of any other federally funded educational program?

- Yes No

If yes, please check which service he/she receives.

Tutoring

Advisement

Campus Visits

Other

Is a parent with which the child lives a graduate of a four-year college or university with a Bachelor’s Degree?

- Yes No

Is the applicant’s native language a language other than English?

- Yes No

Certification of information and acceptance of terms: This is to certify that all information provided herein is true and accurate to the best of my knowledge. I hereby give my permission for the OPEN DOORS PROGRAM at Cameron University to have access to any school or agency records of my child to determine eligibility for the program and to monitor the status and progress in secondary school. Further permission is granted to request information and records from any and all post-secondary institutions and tracking agencies utilizing personal identification information in order to track college progress. In addition, I give my permission for my child’s name, photograph, work and/or statements to be used by Open Doors for promotional, publicity, or instructional purposes. I also give Open Doors staff members permission to communicate with my child via phone, text messaging and computerized social networks. I understand that all records, and information contained therein, will be kept in strict confidence and in accord with the Privacy Act of 1974. Please choose "Yes" to certify the submitted information and indicate your acceptance of terms.

- Yes No

I understand that if, at any time, an Open Doors student chooses non-traditional, LPS instruction, that student must participate in at least two online services a semester, in order to remain active in the Open Doors program.

- Yes No

Parent Signature 1: Please type your name in the signature block below as acceptance of the terms above.

Parent Signature 2: Please type your name in the signature block below as acceptance of the terms above.

Parent/Guardian’s Home Phone Number

Parent/Guardian’s Work Phone Number

Parent/Guardian’s Cell Phone Number

In case of emergency, contact: (Name)

In case of emergency, call: (Phone Number)

Please list name and ages of other children in the family who might be interested in OPEN DOORS:

One of the major goals of the OPEN DOORS program is to encourage parental support of, and participation in program ventures. This may include educational, career planning, and/or social activities. Please indicate your willingness to help with these activities.

I volunteer to work with the following OPEN DOORS committees (Please check one or more)

Fund Raising

Refreshments

Activities and Involvement (Chaperone, Advisory Board, School Enrollment)

Please check all of the services you would like your child to receive:

Study skills and habits

Goal setting/decision making

Organization/time management skills

Tutoring

Communication/listening skills

Personal/Social Skills

Reading/writing skills

PSAT/ACT/SAT preparation

Planning high school/college classes

Scholarships, financial aid, admissions

Career information

What careers and jobs interest your child the most?

For my child to remain eligible to participate in the OPEN DOORS PROGRAM, I will Immediately contact the OPEN DOORS advisor if my child receives disciplinary action at school. Be involved with OPEN DOORS activities as much as possible. Attend OPEN DOORS Parent / Guardian Workshops and Conferences throughout the school year. Encourage my student to attend tutoring sessions. Notify the OPEN DOORS office with address and phone changes. Please choose "Yes" to certify the submitted information and indicate your acceptance of terms.

- Yes No

This survey contains a number of statements about student needs. Please give your honest opinion of how the OPEN DOORS Program can meet your needs. Your answers will be kept confidential.

Academic Needs:

1. To learn how to complete and turn in my homework on time.

1 (Strong Need)

2 (Some Need)

3 (No Need)

2. To get better grades in school.

1 (Strong Need)

2 (Some Need)

3 (No Need)

3. To take tests better and with less anxiety.

1 (Strong Need)

2 (Some Need)

3 (No Need)

4. To organize my time, activities and responsibilities better.

1 (Strong Need)

2 (Some Need)

3 (No Need)

5. To learn more about high school requirements for college.

1 (Strong Need)

2 (Some Need)

3 (No Need)

6. To listen better in class and ask more questions.

1 (Strong Need)

2 (Some Need)

3 (No Need)

7. To relate to and communicate better with my teachers.

1 (Strong Need)

2 (Some Need)

3 (No Need)

8. To identify, set and evaluate goals for the future.

1 (Strong Need)

2 (Some Need)

3 (No Need)

My academic goal is:

Personal Needs:

1. To better understand my parents and other adults.

1 (Strong Need)

2 (Some Need)

3 (No Need)

2. To learn to deal with conflict in a positive manner.

1 (Strong Need)

2 (Some Need)

3 (No Need)

3. To be more accepting of my physical appearance.

1 (Strong Need)

2 (Some Need)

3 (No Need)

4. To learn how my self-esteem affects my behavior.

1 (Strong Need)

2 (Some Need)

3 (No Need)

5. To know how to get along better with the opposite sex.

1 (Strong Need)

2 (Some Need)

3 (No Need)

6. To learn to accept people who are different from me.

1 (Strong Need)

2 (Some Need)

3 (No Need)

7. To learn more about the use/abuse of drugs and alcohol.

1 (Strong Need)

2 (Some Need)

3 (No Need)

8. To accept greater responsibility for my actions.

1 (Strong Need)

2 (Some Need)

3 (No Need)

My personal goal is:

Career and Post-secondary Needs:

1. To explore a variety of career opportunities.

1 (Strong Need)

2 (Some Need)

3 (No Need)

2. To learn more about job applications, resumes, and interviews.

1 (Strong Need)

2 (Some Need)

3 (No Need)

3. To learn more about the postsecondary admissions process.

1 (Strong Need)

2 (Some Need)

3 (No Need)

4. To prepare for exams like the PSAT, ACT, or SAT.

1 (Strong Need)

2 (Some Need)

3 (No Need)

5. To visit more colleges and technology centers.

1 (Strong Need)

2 (Some Need)

3 (No Need)

6. To learn more about college costs and how to pay for college.

1 (Strong Need)

2 (Some Need)

3 (No Need)

Open Doors Program Permission Slip

Parent Signature: Please type your name in the signature block below as acceptance of the following terms. Open Doors Program Permission Slip: My son/daughter has permission to participate in the Cameron University Open Doors Program Activities. I give permission to the Open Doors Staff to act on my behalf should any disciplinary or emergency situation occur. As parent/guardian, I agree to defend, indemnify and to hold harmless the Open Doors Staff, Cameron University and its Board of Regents from any and all claims for loss, costs, damages, and expenses, including reasonable attorney’s fees, which may occur to person or property during an Open Doors field trip, Community Service project or activity.

Open Doors Medical Release

Parent Signature: Please type your name in the signature block below as acceptance of the following terms. Open Doors Medical Release: I authorize the Cameron University Open Doors Program to provide medical services to my child. Follow-up medical care is also authorized. All costs will be assumed by the Parent/Guardian.

Medical Concerns

Please list any medical concerns or physical limitations that the Open Doors Staff should be aware of (e.g., asthma, allergies). If there are no medical concerns type "none"

Open Doors Student Conduct Agreement

Parent Signature: Please type your name in the signature block below as acceptance of the following terms. Open Doors Student Conduct Agreement: I realize that good behavior and an appropriate school dress code is required when participating in Open Doors activities. I am also aware that inappropriate behavior/conduct may be grounds for dismissal from the Open Doors Program. I expect that my child will be on his/her best behavior and act accordingly. Should an incident involving inappropriate conduct occur, I understand that my child will be subject to disciplinary action. I give Open Doors Staff permission to communicate with my child via phone, text messages and computerized social networks.