Fuller Performance Learning Center

Admission Packet
Dear Potential PLC Student:
Thank you for your interest in the Fuller Performance Learning Center (PLC). Please complete and
return the application packet to begin the application process. Once your application has been
received, please allow at least two weeks for your application to be processed. You will be contacted
regarding your testing session and interview with the PLC selection committee.

* PLEASE RETURN YOUR ADMISSION PACKET IN ITS ENTIRETY.

We will not begin reviewing your packet until we receive all documents. *
Please follow the checklist below when turning in your admission packet:

) Student has completed the two page application

) Application: Has it been signed by both the student & parent?
) Student has completed the Student Self Referral Form
) The Guidance Counselor / Administrator recommendation form has been completed and sealed in an
envelope. Please provide counselor / administrators name ___________________________________________

) Student has a copy of Transcript (It does not have to be an official transcript)
) Student has a copy of Discipline Record
) Confidential School Health Form

For Office Use Only:

Date Received:_________________________
_____________________________________

We look forward to reviewing your application!

Follow Up:____________________________
_____________________________________
_____________________________________
_____________________________________

If you have any questions, please call our office at

(910) 488-6262 (Monday Friday, 8:00 am 5:00 pm)
To return your application, please mail or drop-off at:
Fuller Performance Learning Center
314 Jasper Street
Fayetteville, NC 28301
or Fax to (910) 488-3633
Check out our website: www.fplchs.ccs.k12.us.ns
For 2010-2011

Testing Date:__________________________
Scores:_______________________________
Interview Date:_________________________
Status:________________________________
_____________________________________
_____________________________________

CUMBERLAND COUNTY SCHOOLS

FULLER PERFORMANCE LEARNING CENTER
STUDENT APPLICATION
I. Personal Information
Applicants (Legal) Name ___________________________________________________________________|__________________
Last

First

Middle

Preferred Name

D.O.B. ________________ SSN: __________________ School: _____________________ Student ID #_____________________

Ethnic Heritage: (Check One) White_____ Black_____ American Indian____ Multi-Racial_____ Hispanic______ Asian/Pacific Islander______

Student Information:

Is this your mailing address?

Street Address____________________________________________________

If no, please specify:

City_____________________________ State___________ Zip____________

________________________________

Student Home Phone

) ___________________________________

________________________________

Student Cell Phone

) ___________________________________

________________________________

Student Email Address

__________________________________________

Additional Biographical Information

Does the student applying for admission have children?

 Yes  No
Is the student married?  Yes  No
Does the student work?

 Yes  No

If yes, does the child live with the student? ______

Number of hours worked weekly ______________________________________

II. Parent/Guardian Information

Parent/Guardian 1: ___________________________________________________
Employer: ___________________________________________________________

The student resides with

(Check one):

Work Phone: _________________________________________________________

____ Both Parents

Cell Phone: __________________________________________________________

____ Mother Only

____ Father Only

Parent Email Address:_________________________________________________

____ Mother/Step-Father
____ Father/Step-Mother

Parent/Guardian 2: ___________________________________________________
Employer: ___________________________________________________________
Work Phone: _________________________________________________________

____ Grandparents
____ Legal Guardian
____ Living on their own
____ Spouse

Cell Phone: ___________________________________________________________

Parent Email Address: _________________________________________________

____Other (

III. Emergency Contact Information

Contact 1 __________________________________________

Contact 2 ___________________________________________

Relationship to Student______________________________

Relationship to Student_______________________________

Address____________________________________________

Address____________________________________________

___________________________________________________

____________________________________________________

Phone #: __________________________________________

Phone #: ___________________________________________

IV. Curricular & Extracurricular Activities

Is the student identified in the Academically Gifted education program?
Does this student have a 504 plan?

 Yes  No

: Yes : No

If yes, please provide a copy

Is this student an ESL student (English as a second language)?

 Yes  No

Has this student ever been identified in the exceptional childrens/special education program?
* If yes, please provide a copy of IEP.
Is this student currently identified in the exceptional childrens/special education program?
* If yes, please provide a copy of IEP.

 Yes  No

 Yes  No

What subject(s) do you consider your strengths? __________________________________________________________________

_____________________________________________________________________________________________________________
In what subject(s) have you had the most difficulty? _______________________________________________________________
_____________________________________________________________________________________________________________
What colleges are you interested in attending?____________________________________________________________________
_____________________________________________________________________________________________________________
What profession(s) or vocation(s) are you considering? ____________________________________________________________
_____________________________________________________________________________________________________________
Check the activities that you have participated in:
_______ Chorus

_______ Student Government

_______ Honor Societies

_______ Band

_______ Newspaper

_______ Creative Arts

_______ Service Organization

_______Yearbook

Other_____________________________________

Sports (Specify): ______________________________________

__________________________________________

_____________________________________________________

In compliance with federal law, Cumberland County Schools administers all educational programs, employment activities and admissions without
discrimination against any person on the basis of sex, race, color, religion, national origin, age of disability.

To the best of my knowledge, the information in this application is true and accurate. By signing below I give
permission for my child to be assessed for possible admission to the Cumberland County Schools Fuller Performance
Learning Center.
Date____________________

X
Parent/Guardian Signature
X

Date____________________
Student Signature

Fuller Performance Learning Center

Student Self Referral Form

STUDENT NAME:_____________________________________ GRADE:_____________________

DATE:________________

ADDRESS: ___________________________________________ CITY:________________________

PHONE:_______________

** STUDENTS TRANSCRIPT MUST ACCOMPANY THIS REFERRAL. **

PLEASE INDICATE POSSIBLE REASONS FOR TRANSFERRING TO FULLER PLC:

 Been Retained (held back) one or more years

 Been Absent Frequently from School
 Been Late to School Frequently
 Feel Like You Do Not Fit in at School
 Skipped Classes Frequently

 Failed 2 or more subjects in recent semester

 Had Difficulty Understanding Math
 Have Little/No Interest in School
 Do Not Get Along with Teachers at School
 Excessive Work Schedule

WHY DO YOU WISH TO ATTEND THE PERFORMANCE LEARNING CENTER? WHAT DO YOU
HOPE TO GIVE TO AND GET OUT OF THE EXPERIENCE? (Please write your response in this space. You
may continue your response on the back if needed)

Fuller Performance Learning Center

Guidance Counselor / Administrator

Recommendation

To Applicant:
Please Print or type this section and deliver this form to your guidance counselor or principal. The
Evaluator will seal these forms in an envelope.
* This form will not be considered valid if not sealed. *
Applicants Name _________________________________________________Grade________________
Last

First

Middle

(Current)

Street Address __________________________________________________________________________

City_________________________________

State__________________

Zip_____________

X___________________________________________________
Date ______________________

Parent Signature

X___________________________________________________
Student Signature

To Evaluator:
The student named above has applied for admission to the Fuller Performance Learning Center. This
form is included in our admission packet. Please complete this form and seal it in an envelope. The
information will not be included in the students permanent file. Please confer with professional
colleagues to ascertain information, if necessary. Thank you.

Evaluators Name ______________________________________________________________________

Title __________________________________________ School__________________________________
Street Address _________________________________________________________________________
City ___________________________________ State ___________________ Zip___________________
Telephone __________________________________

DISCIPLINARY TRACKING RECORDS MUST ACCOMPANY THIS REFERRAL FORM.

PLEASE ATTACH TO THIS FORM.

PRIMARY REASON FOR REFERRAL TO FULLER PERFORMANCE LEARNING CENTER:

* Academic Failure not enough credits

* Excessive Absenteeism absences impeding the students education
* Excessive Tardiness late to class
* Apathy/Indifference to Education no interest in school
* Social Issues student exhibits poor self-esteem/does not interact well with peers.
* Other (please specify): _________________________________________________________________________
PLEASE CHECK ANY FACTORS OR CHARACTERISTICS LISTED BELOW WHICH APPLY TO STUDENT

1. POOR ACADEMIC ACHIEVEMENT

* Retained (held back) one or more years

* Grades are well below potential of students
* Failed 2 or more subjects in recent semester
* Student in need of remediation
* Other (please specify):
___________________________________________________________________________________________
2. EXCESSIVE UNEXCUSED ABSENCES/TARDINESS/SKIPPING CLASSES

* Absent _______ days last year/semester/marking period (please circle time period)
* Late to school _______ days last year/semester/marking period (please circle time period)
* Student skipped _______ classes last year/semester/marking period (please circle time period)
* Other (please specify):
___________________________________________________________________________________________
3. APATHY/INDIFFERENCE TO EDUCATION

* Little/No Interest in School

* Student Needs to be Challenged/Student is Bored
* Student Does Not Fit in at School
* Other (please specify):
____________________________________________________________________________________________
4. SOCIAL ISSUES

* Low Self Esteem

* Does not interact well with peers
* Student does not interact well with teachers/school administration
* Other Issues (Anxiety, ADD, ADHD, ODD): Please explain
__________________________________________________________________________________________

How long has the student been enrolled at your school? __________________________________________________________
How long have you known the student? _______________________________________________________________________
Do any of the following apply for this student?

* ESL * Learning Disability * Other Exceptionality

Please specify: ________________________________________________________________________________________

To your knowledge has the student had any history of serious conduct problems and/or emotional problems?

* Yes
* No

If yes, please explain. _________________________________________________________________________________________

_____________________________________________________________________________________________________________

To your knowledge has the applicant ever been expelled or suspended?

Yes
No
If yes, please explain. __________________________________________________________________________________________
_____________________________________________________________________________________________________________
Describe the students strengths ________________________________________________________________________________
_____________________________________________________________________________________________________________
Please comment on the applicants attitude toward school. _________________________________________________________
____________________________________________________________________________________________________________
Please complete the appropriate blanks. As with the above questions, you may desire to confer with colleagues to make
your recommendation.
No Basis for Below
Average
Judgment Average

Good

Excellent

Outstanding
Motivation
Creative Qualities
Self-Discipline
Growth Potential
Leadership
Self-Confidence
Personal Appearance
Warmth of Personality
Sense of Humor
Concern for Others
Energy
Emotional Maturity
Personal Initiative
Reaction to Setbacks
Physical Condition
Respect for Authority
School Conduct
Our of School Conduct

Additional Comments: ________________________________________________________________________________________

_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
* Please feel free to attach a letter of recommendation or any other pertinent documents. *
Date ____________________

X_________________________________________________________________
Evaluators Signature