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

Complete this online application and submit it electronically.

Student Information

* denotes a required field

Date of Application: Monday, 11/30/2015 11:04 PM
Student UID:*

Term applying for:


/ /
Name of person who referred you to CRP?:*

Referrer's Department:*

Year Level:

Your current major:*

Your current cum. GPA:*

Are you currently facing:

What were the circumstances or behaviors that resulted in your being suspended/put on probation?*
Home Phone Number:

Cell Phone Number:

Apt. / Dorm Phone Number:

E-mail Address:*
(Note: Students must use their RIT e-mail address.)
Students with incompletes are not eligible for CRP. Do you currently have any incompletes?

Are you planning on taking any summer classes?

If Yes, which course and where?
Status: (check any that apply)

Your address at RIT:
Street Address:*



Zip/Postal Code:*

Local/Cell Phone:*
( )- - (if necessary CRP faculty and staff will contact you using this number)


Please indicate your ethnic origin (for research purposes only)

Parent/Guardian Information*


Street Address:*
Zip/Postal Code:*
*Parent's/Guardian's name & home address: (Required for students under 24 years of age)

Street Address:*
Zip/Postal Code:*
Family Information
Family Member Gender Age Occupation Highest Level Of Education

Emergency Information

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

Phone Number:*
( ) -

Financial Information

Do you receive financial aid (loans, grants, scholarships)?
Do you have an academic performance contract with the Office of Financial Aid?
Do you have a tuition waiver?
Are you in the tuition exchange program?
Who is responsible for your college expenses?


Academic History

List other colleges attended and credit hours earned.

College 1

Credits Earned:

College 2

Credits Earned:

High School Attended:




Do you plan on working while in CRP? (It's recommended that students work no more than 15 hrs/week)
If so, where?

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? (Please note that you may be asked by the person in charge of the club/organization, to relinquish your leadership duties during the CRP term)*
Which of these activities/organizations would you like to continue to be involved in during the CRP term?*

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 Term.*


Important note: Please read carefully and check the boxes below to confirm your agreement to the following CRP 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. CRP reserves 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 reinstated into an RIT academic program. CRP will provide a written final report to the department of your choice for reinstatement; however, the final decision of reinstatement is determined by the individual department head.
  4. CRP follows RIT’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 CRP has the right to communicate with your current professors, department heads, deans and other administrative offices such as the Office of Financial Aid, Residence Life, Student Financial Services, Athletics, Registrar's and Student Conduct, as well as to parents in regard to your academic performance and contributing factors.

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 his or her age or dependent status.

Permission to Release Information

While I am in the College Restoration Program I, , hereby give my permission to allow CRP faculty, staff, and mentors to share information relating to my academic performance with third parties. This includes, without limitation, my current term instructors, deans, department heads, academic coordinators and advisors, as well as my parents, RIT administrative offices such as Financial Aid, Registrar's, Student Financial Aid, 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-Term , and the CRP Final Summary Report. In addition, I understand that if my parent/guardian calls/e-mails my CRP mentor or the Program Cordinator, 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,2120 SAU, 475-2982,

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 CRP 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 instructors, Year one coaches, department heads, and academic advisors. In addition, we may communicate with certain administrative offices such as Financial Aid, Registrar’s, Student Financial Services, 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.

Our communication with parents includes a welcoming letter to verify the student’s participation in CRP, and copies of the Mid-Term Grade Report and the Final CRP Report which are sent to parents as well as 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. We may recommend that a student seek a professional evaluation and/or access campus resources available to them. Any concerns regarding CRP's policy can be directed to Dawn Herman, SAU-2120, 475-2982,

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 is the student's.

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.


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. I...
(1) Agree, (2) Disagree.
Have difficulty managing my time
Have trouble getting and staying motivated
Have trouble completing assignments on time
Have trouble starting assignments
Spend too much time doing non-academic activities such as internet, socializing, gaming
Don't attend classes as regularly as I should
Don't put enough time into homework/studying
Not organized
Don’t use resources on campus (i.e., professors, study centers) 
Don’t have an effective study environment 
Feel my grades don’t reflect my abilities 
Have trouble taking lecture notes 
Have trouble taking notes from a textbook 
Have trouble studying for tests 
Freeze up and can’t remember anything on tests 
Am questioning my ability to succeed at RIT
What is the next math course you need to pass for your major?*
I am done with my math sequence
What RIT math resources do you use on a regular basis? (check all that apply)
Describe what you do to learn math well
I have difficulty with writing assignments and/or writing courses
I have difficulty with reading comprehension, vocabulary, etc.
I have difficulty with the English language
What type of writing resources do you use?*
What writing courses do you have to take?*
MAJOR Agree Disagree
What made you decide to go into your current major?*
My current major doesn't match my skills and abilities
My current major no longer interests me, and I'm interested in exploring other majors.
CAREER Agree Disagree
My major is not the issue. I need help with "career","job prep" issues
Don't feel connected to RIT
Have had difficulty adjusting to college life in general
Have concerns about my relationships with friends
Have concerns about my relationships with parents and family
Experiencing the loss of a significant person in my life
Feel shy and/or unassertive
Often experience feelings of irritablity, anger, and/or hostility
Often experience feelings of low self-esteem, low self-confidence
Feel lonely and/or homesick
Experience depression/long periods of sadness
Experience anxiety, fears, and/or worries often
"Party" a lot
PHYSICAL Agree Disagree
Feel physical stress (headaches, stomach pains, muscle tension)
Have trouble eating healthy
Have trouble sleeping
Sleep through the morning/day and miss classes
Fall asleep in class
Have you been required to meet with someone to discuss a violation of RIT policies?
Please respond to all of the following questions using the text boxes provided.
If you have been required to discuss a policy violation, please provide a brief explanation.

What would you like CRP faculty and staff to know about you?

What do you feel are the major issues hindering your academic progress?
List the top four (4) reasons contributing to your application and referral to CRP:
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:*
Diagnosed Attentional/Learning Problems NO YES
1.) I would like to identify myself as someone with a learning disability &/or ADD/ADHD.
2.)If yes, are you registered with the Disability Services Office (DSO) and using DSO approved accomodations?
3.) Would you like to consult with an educational specialist regarding your learning disability &/or ADD/ADHD?
Academic Contract
College Restoration Program
Rochester Institute of Technology

This document is the "Academic Contract" I will uphold if accepted into the College Restoration Program (CRP). By providing my initials next to each category, I confirm that I have read and agreed to each item.

  1. I have provided a working phone number where I can be reached. If I cannot be reached, CRP has the right to contact my parents/guardians.
  2. I give CRP permission to contact my parents/guardians via the Initial Parent/Guardian Letter, Mid-Term Grade Report, and the CRP Final Summary Report.
  3. I will read my RIT e-mail daily. If I have another e-mail address I must arrange to have my mail forwarded to my RIT account.
  4. I will attend all "credit" and CRP classes, labs, study groups, conferences, and mentor meetings. CRP does not distinguish between "excused" and "unexcused" absences, which are recorded for each CRP class I miss and on a daily basis. I understand if I have five (5) or more class, and/or mentor meeting absences I will receive a written warning. If I have eight (8) or more individual class and/or mentor meeting absences I will be contacted by the CRP Program Coordinator, and my parents may also be contacted. I understand that if illness or anything else prevents me from attending class(es)/mentor meetings, I need to notify all instructors and my mentor, even though I will accrue an absence(s).
  5. I will complete & submit all "quality" assignments on time, in class, on the day they are due and there may be negative consequences for not turning in assignments, and I may not be allowed to make up ANY missing assignments.
  6. I will meet all financial obligations to the Institution.
  7. I agree to abide by the RIT and CRP code of conduct,policies,procedures as outlined in the Students' Rights and Responsibilities and CRP Handbook and the Program Coordinator. Failure to do so may result in unsuccessful completion of CRP, thus being placed on suspension.
  8. I understand that there are no course withdrawals from CRP or credit courses, and I will not try to alter my course schedule at any time while in CRP.
  9. I understand that the consequences for breach of this contract may result in suspension.

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