For the purposes of providing better services to our students, the Dorchester Higher Education Resource Center counselors need to obtain copies of the student's cumulative academic records. These grades are a requirement of admission to the Passport Program. More importantly, they are a guide by which the program can provide effective tutorial support. The parent/guardian signature at the end of this application gives permission to the Dorchester Higher Education Resource Center Counselors access to the student's academic records.

Name of School:  Six digit CEEB Code:

Expected Year of Graduation:  Homeroom Teacher:

School Telephone:  E-mail:  Fax:

School Street Address:  Do you qualify for free or reduced lunch? Yes  No

City:  State:  ZIP Code:

Guidance Counselor or College advisor:

Name of Parent/Guardian:

Address:  Phone:

City:  State:  ZIP Code:

Relationship:

Parent Work Telephone number:

Mother's Profession and highest education level reached:

Father's Profession and highest education level reached:

Household income range:

In signing this contract below, all parties involved acknowledge that they have read, understand and agree to the terms outlined in the contract. They also certify that the information given in this application is complete and accurate. The contract must be signed by the student, parent/guardian before it becomes a valid contract and the student is officially admitted as a Passport student. $180 is due before your application is accept.

Signature of applicant:    Date:

Signature of parent:    Date: