Pennsylvania Leadership Charter School
University Scholars Program
Application for Participation: 2022-2023 School Year

1585 Paoli Pike

West Chester, PA 19380
E-mail: universityscholars@palcs.org
Phone: 610-344-0524
Fax: 610-344-2898

1. Participation Preference (pleasecheck one):	Cyber/Virtual	Cyber/Virtual/On-site

2. Student Information	In Process or Enrolled with PALCS	PALCS Registration Packet Enclosed

Last Name 	First Name 	Middle Initial Address 	

 	City

 	State 	Zip Code  	

County
Mailing Address
(if different)	 	

Telephone Number

City 	State 	Zip Code  	

Date of Birth	 		Age 	Gender:    Male      Female	Grade Entering Fall 2022  	

3. School District of Residence and Current School Information

District of Residence	 	

Current School Information	     District School	    Charter School	    Home School	    Non-Public School

Name of Current School    	

City	 		State 		Zip Code  	

4. Parent/Guardian Information

Child lives with
(check one)

     Both Parents	      Both Parents Alternately	     Father Only	    Mother Only      Legal Guardian	    Foster Parents	     Other Adult

Primary Parent/Guardian Name 	Relationship to Student  	

Address (if different) 	City 	State 	Zip Code  	

Home Phone 	Work Phone 		Cell Phone	 			 Email Address 		Day Time Contact Preference: Home	Cell	Work
Parent/Guardian Name 		Relationship to Student   	 Address (if different) 	City 		State 	Zip Code  	
Home Phone 	Work Phone 	Cell Phone   	

Email Address 	Day Time Contact Preference: Home	Cell	Work

5. Background Information

What has been your child's previous experience with gifted programming?

Please write a short explanation of why you are interested in having your child admitted to the University Scholars Program.

Has your child participated in any of the following services? If yes, please provide a copy of the most recent report.
  GIEP	  IEP	  504 Plan

6. Student Response

Please have your child review the University Scholars Program website and write a short description of why he/she would like to participate in the Program.

7. Please check all the classes your child has taken.	
Math	 Pre-algebra	 Algebra	 Geometry	  Algebra II	 Trigonometry	 Pre-Calculus
 Calculus	 AP Calculus AB	 AP Calculus BC	  AP Statistics	  Linear Algebra	

English	 American Literature	  British Literature	  World Literature	  Comparative Literature
 AP English Literature & Composition	 AP English Language & Composition	  Other    		

Science	 Biology	 Chemistry	 Earth Science	  Environmental Science	 Life Science
Physical Science		Physics	AP Biology	AP Chemistry	AP Environmental Science  AP Physics B	 AP Physics C: Elec.& Magnetism	 AP Physics C: Mechanics	  Other   		

Social Studies	 Economics	 European History	 Psychology	 Sociology	  U.S. Government
 U.S. History	 World History	 AP Comparative Government & Politics	  AP European History    AP Human Geography	 AP Macroeconomics	 AP Microeconomics	 AP Psychology
 AP U.S. Government & Politics    APU.S. History	 AP World History	 Other:   		
Technology	 C++	 CAD	 JAVA	 Gaming	 HTML//Web Design	 Computer Science 
AP Computer Science A	 AP Computer Science Principles	 Other:	 		
List Foreign Languages studied.
Language	Years studied	Spoken at Home	Fluent in the Language	

		 		

 	 	 		

8. Describe your child

What do you see as your child's strengths?

What are his/her challenges?

What are your child's work habits and attitude about school?

Has your child had any disciplinary actions at his/her current school?	   No	   Yes	If yes, explain below.

Has your child ever been suspended or expelled from school?	No	Yes	If yes, explain below.

Is your child an active member in any leadership, sports, or service organizations?

8. Describe your child (continued)

Tell us about your child's hobbies and special interests.

What summer enrichment programs has your child participated in?

Is there anything else you would like us to know about your child or your family that would help us better understand your child's intellectual, socio-emotional, or academic needs?

How did you hear about the University Scholars Program? (check all that apply)

   Internet Search

University Scholars student or family member 	

  Information Session   Reputation

  PA Leadership Charter School

  Website	

  Academic Competitions or Events	   Other (please specify)    	

Participation in the University Scholars Program is limited. Thank you for taking the time to complete this form.

Send completed participation forms via mail, fax, or email:

How to contact the University Scholars Program

Mail to:	University Scholars Program
Attn: Admissions 1585 Paoli Pike
West Chester, PA 19380
E-mail to:	universityscholars@palcs.org
Fax to:	610-344-2898

Phone: 610-344-0524
610-701-3333 x 1286
E-mail: universityscholars@palcs.org

Parent/Guardian Full Name

Parent/Guardian Signature

Date

Student Full Name

Student Signature

Date

By signing below, it is acknowledged that all the information contained herein is true and accurate. In addition, we, the parents/guardians, and I, the applicant, freely and voluntarily waive the right to access any and all teacher recommendations submitted.