StudentsFaculty/StaffParents

College Restoration Program: Application

Note: Students must first be referred to the College Restoration Program by an academic department head before completing an application.

Complete this application and submit it electronically to Jackie Perez in the Academic Support Center

To secure a spot in CRP, students must contact the main office at 585-475-5536 to schedule their intake appointments.

Student Information
Date of Application: Tuesday, 11/24/2009 6:04 AM
Name:
Student ID:
Quarter applying for: Fall
Winter
Spring
Age:
Birthdate: / /
Referrer's Name:
Referrer's Department
Year Level: 1 2 3 4 5
Your current major:
Your current cum. GPA:
Are you currently facing: academic probation
academic suspension
neither
What were the circumstances or behaviors that resulted in your being suspended/put on probation?
Home Phone Number:
(XXX-XXX-XXXX)
Cell Phone Number: (XXX-XXX-XXXX)
Apt. / Dorm Phone Number: (XXX-XXX-XXXX)
E-mail Address:
(Note: Students in CRP must use their RIT e-mail address.)
Do you currently have any incompletes? Yes No
RIT is committed to providing reasonable accommodations to students with disabilities. If you need accommodations such as special seating, testing modifications, or note taking services due to a disability, please go to the Disability Services Office. It is located in the Eastman Building, Room 2342. Have you already have been approved for academic accommodations at RIT? Yes No
Status:
(check any that apply) 		Regular
Transfer
HEOP
International Student
Use Interpreters
ESOL (English Speakers of Other Languages)
Structured Monitoring Program (formerly LSS)
TRiO Student Support Services
Other
Your address at RIT:
Street Address:
City:
State:  
Zip/Postal Code:
Local/Personal Phone: ( ) -
(unless otherwise indicated, this number will appear on a list that will be given to all CRP students for group projects)
Parent Information
Parent's name & home address: (Required for students under 24 years of age)
Name(s):
Street Address:
City:
State:  
Zip/Postal Code:
Financial Information
Do you receive financial aid (loans, grants, scholarships)? Yes No
Do you have an academic performance contract with the Office of Financial Aid? Yes No
Do you have a tuition waiver? Yes No
Are you in the tuition exchange program? Yes No
Who is responsible for your college expenses? Name:
Relationship:
Academic History
List other colleges attended and credit hours earned.
College 1 Name:
Credits Earned:
College 2 Name:
Credits Earned:
High School Attended:
Name:
City:
State:
Family Information
Family Member Gender Age Occupation Highest Grade Completed
Parent M F
Parent M F
Sibling M F
Sibling M F
Sibling M F
Emergency Information

Please list the name and phone number of the person we should contact in case of an emergency

Name:
Relationship:
Phone Number: ( ) -
Ethnicity
Please indicate your ethnic origin
(for research purposes only)		 Caucasian
Black, Non-Hispanic
Hispanic
Asian or Pacific Islander
Native American or Alaskan Native
Other
Employment
Do you plan on working while in CRP? Yes No
If so, where?
Approximately how many hours a week do you want to work?
Student Activities and Organizations
What extra-curricular or co-curricular activities have you been in involved in?
What, if any, leadership positions do you hold in any of these student organizations?
Which of these activities/organizations would you like to continue to be involved in during your quarter in CRP?
Reason for Participation
Please explain why you want to participate in the College Restoration Program, what you hope to accomplish, and what your goal(s) are for the CRP Quarter.

Policies

Important note: Please read carefully and check the boxes below to confirm your agreement to the following conditions and policies.

  1. CRP does not discriminate on the basis of age, color, disability, gender, national origin, race, religious creed, sexual orientation and/or veteran status.
  2. We reserve the right to reject applicants whom we feel are not appropriate candidates for CRP.
  3. Participating in and successfully completing CRP (by earning a 2.0+ CRP GPA) does not ensure that you will be re-accepted into an RIT academic program. We will provide a written final report recommending reinstatement; however, this final decision is determined by the individual department head.
  4. CRP follows the Institute’s policy of sharing information in relation to a student’s academic progress, or lack thereof, on a “need-to-know” basis. This means that we have the right to talk to your current quarter professors, department heads, deans and other administrative offices such as the Office of Financial Aid, Residence Life, Bursar’s, Athletics, Registrar’s and Student Conduct, as well as to parents in regard to your academic performance and contributing factors.
  5. The only time we will not communicate with parents is when a student’s parents have provided to the registrar a copy of their most recent federal tax return as proof of the student’s financial independence.

Permission to Release

Before submitting this form, please read the explanation of student rights under FERPA and CRP’s policies for sharing information related to academic performance.

All students wishing to participate in the College Restoration Program must submit this form no matter what the age or dependent status (unless you have a formal declaration of emancipation filed with the Registrar’s Office and do not want our office to contact your parents).

If you have filed a formal declaration of emancipation with the Registrar’s Office, please check here:

Permission to Release Information

While I am in the College Restoration Program I, , hereby give my permission to allow ASC faculty, staff, and mentors to share information relating to my academic performance with third parties. This includes, without limitation, my current quarter instructors, deans, department heads, academic coordinators and advisors, as well as my parents, RIT administrative offices such as Financial Aid, Registrar’s, Bursar’s, Housing, Athletics, Disability Services, and Student Conduct.I understand that the Federal Educational Rights and Privacy Act of 1974 (FERPA) protects the privacy of my educational records and I specifically consent to the release of these records to third parties as mentioned in this application.

I understand that there will be at least three documents that will be sent to my parents: a welcoming letter, the Mid-Quarter Progress Note, and the CRP Final Report. In addition, I understand that if my parent/guardian calls/e-mails my CRP mentor or the program director, these people will return the call/e-mail and respond to any inquiry related to my academic performance. I also understand that this communication may include observations about my behavior in the classroom, professional opinions about my behavior as it relates to learning, disability information or medical/psychological information, and recommendations for further evaluation or for resources available to me at RIT. Any concerns regarding CRP’s policy can be directed to Dawn Herman, Director, CRP, 2383 Eastman, 475-2982, dawn.herman@rit.edu.

Release of Student Information in CRP

If you are eighteen years or older and/or a college student, the Federal Educational Rights and Privacy Act of 1974 (FERPA) protects the privacy of your educational records. Essentially, FERPA is “applicable to schools/colleges that receive federal funds (or their students receive federal funds)...and “provides parent/student access to educational records” ...while at the same time protecting “the privacy of those records.” (Nixon Peabody LLP 06/03)

In regard to our work with students in the College Restoration Program, FERPA allows us, the ASC faculty, staff, and mentors, to share information of “legitimate educational interest” within RIT. This means we have the right to share information, such as your transcript or academic advising report, and any further information, including our professional opinion, relating to your academic progress or lack thereof on a “need to know” basis. Typically, we may share information with your current quarter instructors, FYE coaches, department heads, and academic advisors. In addition, we may communicate with certain administrative offices such as Financial Aid, Registrar’s, Bursar’s, Disability Services, Housing, and Student Conduct. The type of educational records includes your grades, grade point average (GPA), your course schedule, a record of misconduct (but not the specific behaviors) and any other information relating to your academic performance.

In order for the ASC faculty, staff and mentors to work with students facing probation or suspension, we ask each applicant to sign and date a Permission to Release Information form, no matter what the age or dependent status. Our communication with parents includes a welcoming letter to verify the student’s participation in CRP, and copies of the Mid-Quarter Progress Note and the Final CRP Report which are sent to parents as well as to the student. We will not conduct outreach to parents unless we suspect the student is in harm or harming others; however, if a parent inquires, we will provide “educational information” on a “need to know” basis. We will not disclose personal information unless it directly relates to academic performance. This includes our diagnostic opinions of behaviors suggesting a learning or emotional disability. However, we may recommend that a student seek a professional evaluation and/or access campus resources available to them. For students who have filed a formal declaration of emancipation with the Registrar’s Office, we will not send any correspondence to parents. For students who are financing their college education, we still have the right to correspond with parents unless there is a formal emancipation filed with the Registar’s Office. Any concerns regarding CRP’s policy can be directed to Dawn Herman, Director, CRP, 2383 Eastman, 475-2982, dawn.herman@rit.edu.

Students need to be aware that disclosing disability information or medical/psychological information in their final letter of appeal for reinstatement means that this information will be in their academic folder. Department heads, faculty, and advisors have legal right to access any information in the student’s academic folder since it is a formal “educational record.” We encourage students to avoid including personal information or any disability specifics in their letter. However, the final decision comes down to the student.

CRP faculty and mentors are also aware that they are often privy to sensitive information when working with their students in CRP. However, any formal reports will reflect their observations, professional opinions, and recommendations in general terms in order to respect the privacy of the student.

For further information on RIT’s and CRP’s compliance with the Family Educational Rights and Privacy Act of 1974 (commonly known as the Buckley Amendment), please see RIT’s “RIT Educational Records” in the handbook of Student’s Rights & Responsibilities.

02/06/06

Type your name to confirm your understanding of CRP's Permission to Release Information policy:
Please read this list and indicate how the statement best describes you while at RIT (use the following scale)
The statement describes me.
not at all (1), very little (2), somewhat (3), fairly well (4), perfectly (5).
TIME MANAGEMENT 1 2 3 4 5
Have difficulty managing my time
Procrastinate
Have trouble getting motivated
Have trouble staying motivated
Have trouble completing assignments on time
Spend too much time on the computer doing non-academic activities
Spend too much time hanging out, watching TV or movies
Don't attend classes regularly
Don't put enough time into homework/study
Not organized
STUDY SKILLS AND LEARNING STYLE 1 2 3 4 5
Don’t use resources on campus (i.e., professors, study centers) 
Don’t have an effective study environment 
My grades don’t reflect my abilities 
Have trouble taking lecture notes 
Have trouble studying for tests 
Freeze up and can’t remember anything on tests 
Am questioning my ability to succeed at RIT
CAREER 1 2 3 4 5
What made you decide to go into your current major?
My current major doesn't fit my skills and abilities
My current major no longer interests me
I am interested in exploring other majors
I have decided on a new major
SOCIAL / INTERPERSONAL 1 2 3 4 5
Don't feel connected to RIT
Have had difficulty adjusting to college life in general
Have concerns about my relationship with roommate(s)
Have concerns about my relationships with friends
Have concerns about my relationship with romantic partner
Have concerns about my relationships with parents and family
Am feeling the loss of a significant person
Feel shy and/or unassertive
Experience irritable, angry, and/or hostile feelings often
Experience feelings of low self-esteem, low self-confidence
Feel lonely or homesick
Experiencing depression
Experiencing anxiety, fears, and/or worries often
"Partying" a lot
PHYSICAL 1 2 3 4 5
Feel physical stress (headaches, stomach pains, muscle tension)
Have trouble eating healthy
Have trouble sleeping
Sleeping through the morning/day and missing classes
Fall asleep in class
OPEN ENDED QUESTIONS
Have you been required to meet with someone to discuss a violation of RIT policies?
Please respond to all of the following questions usiing the text boxes provided.
If you have have been required to discuss a policy violation, please provide a brief explanation.

Is there anything else you would like us to know about?

What do you feel are the major issues hindering your academic progress?
Please prioritize the level of hindrance to your academic progress and explain why in the text box provided 1st 2nd 3rd
Academic skills issues (math, reading, writing, problem-solving, etc)
Please explain why:
Personal issues (difficulty establishing independence or responsibility, low self-esteem, relationship problems, etc)
Please explain why:
Career issues (confused or unhappy with major, picked major for the wrong reason, want to explore new possibilities, etc)
Please explain why:
Please read this list and indicate how the statement best describes you while at RIT (use the following scale)
The statement describes me. not at all (1), somewhat (2), a lot (3).
SCREENING FOR SPECIFIC LEARNING DIFFICULTIES 
Attention 1 2 3
I have difficulty paying close attention to details or make many careless mistakes in schoolwork. 
I have trouble sustaining my attention or focus for long periods of time. 
People often think I am not listening or paying attention to them. 
I have difficulty following through on projects despite planning to and intending to complete them. 
I have great difficulty organizing tasks, activities, papers, etc. 
I avoid or dislike work that requires intense or sustained attention or work (like long homework assignments). 
I lose or misplace things much more often than it seems that others do (keys, cell phone, books, papers, assignments, etc.) 
I am easily distracted by other people, noises, or activities when in class, when studying, or when taking a test. 
I have difficulty sitting still - find myself fidgeting (bouncing leg, tapping fingers, wriggling, etc.) 
I have trouble staying in my seat in classes and sitting in one place for long periods of time. 
I have a feeling of “restlessness”/“edginess” most of the time. 
I have difficulty engaging in relaxing or leisurely activities. 
I often have lots of things going on - like to be “on the go.” 
Friends/family describe me as very talkative - a “fast talker.” 
I often blurt out responses or cut people off before they are finished. 
I am impatient when I have to wait for something or wait my turn. 
I interrupt or intrude upon others, even when they are talking with someone else or doing something else. 
I often engage in risky activities (sports, driving, drinking, drug use, etc.) . 
My moods are unpredictable or I am easily irritated a lot of the time. 
I feel sad or depressed a lot of the time. 
I worry or feel anxious a lot of the time. 
I have felt these symptoms or been this way since I was very young. 
I feel this way or have these symptoms in almost all settings (school, home, work, social life). 
General Learning 1 2 3
Feel like it takes me much longer to do a math problem, write a paper, or read a book than others. 
Feel like I forget what I have learned quickly, even when I try to take steps to remember. 
Have difficulty following written directions. 
Have difficulty following spoken directions. 
Mathematics 1 2 3
Have difficulty with computations in mathematics. 
Have difficulty with word problems in mathematics. 
Have difficulty understanding procedures in mathematics. 
Have difficulty understanding concepts in mathematics. 
Make “silly mistakes” when doing math. 
Reading 1 2 3
Have difficulty understanding what I read. 
Have difficulty remembering what I read. 
Have difficulty understanding vocabulary in reading assignments. 
Feel like I am a “slow reader.” 
Writing 1 2 3
Have difficulty organizing my ideas before writing or speaking. 
Have difficulty getting my thoughts down on paper the way I want them to be. 
Make lots of grammar or spelling errors in my writing. 
My handwriting is hard to read. 
Diagnosed Attentional/Learning Problems NO YES
I have ADD/ADHD; therefore I would like to identify myself as a student with a disability.
I have a learning disability; therefore I would like to identify myself as a student with a disability.
I suspect I have ADD/ADHD and would like to be screened.
I suspect I have a learning disability and would like to be screened. 
Someone in my family has been diagnosed with ADD/ADHD. 
Someone in my family has been diagnosed with a learning disability.

I would like to identify myself as someone registered with Disability Services at RIT.
I would like to identify myself as someone who uses Academic Accommodations at RIT 

I agree to the conditions and policies listed in the "Policies" section of this application.

All the information I have provided in this application is true to the best of my knowledge.