Personal Information

Student Legal First Namerequired

Student Legal Last Namerequired

Preferred Name

Date of Birthrequired (mm/dd/yyyy)

Gender*

M F

Student Home Addressrequired

Address 2

City

State

Zip

Current School required

Religionrequired

Parish or Churchrequired

Family Information

Father's First and Last Namerequired

Father's Email Addressrequired

Father's Phone Numberrequired

Is address different from student?*

Yes No

Address 1

Address 2

City

State

Zip

Mother's First and Last Namerequired

Mother's Email Address required

Mother's Phone Numberrequired

Is address different from student?*

Yes No

Address 1

Address 2

City

State

Zip

With whom does the applicant live?required

Language(s) Spoken at Homerequired

Siblings (List Name, Grade, and School)

MSM Alumni Relatives

List maiden name, year of graduation/attendance, and relationship to applicant.

Parent Response Questions

Please explain why you want your child to participate in the Cornerstone Inclusion Program.required

What are your expectations for your child as a student of Mount St. Mary Catholic High School?required

How do you see your child adapting to the Cornerstone Inclusion Program?required

What are the areas where this student excels?required

How would you describe this student's personality?required

Is this student currently enrolled in any tutoring, special programs or classes outside of his/her regular school day?*

Yes No

If yes, please explain:

Has your student received counseling in the past 5 years? *

Yes No

If yes, please list a brief reason why?

Have there been any changes in this student's family in the past 5 years?

(Examples include: divorce, death, moves, remarriage)

Cornerstone Inclusion Program

PHILOSOPHY AND PURPOSE

Building upon the mission of Mount St. Mary Catholic High School, the Cornerstone Inclusion Program supports the belief that all students deserve the opportunity to maximize their academic, social, and spiritual potential. The vision at Mount St. Mary is that students from a wide range of intellectual abilities will continue to learn and advance if provided a rich, rewarding Catholic learning environment.

PROGRAM EXPLANATION

The Cornerstone Inclusion Program provides an inclusive educational experience for students with intellectual disabilities. Students benefit from inclusion opportunities in a variety of academic courses for 100% of the school day. Students in The Cornerstone Program receive more individualized instruction as needed to facilitate their continued academic progress. All students will be given a "Certificate of Achievement" upon completion of the program, rather than a high school diploma. Students accepted into the Cornerstone Inclusion Program incur an additional $1,000 fee per year.

ADMISSION PROCESS

The application process for the Cornerstone Inclusion Program will take place in two parts.

1) Application for Admission

2) Interview with the prospective student and parents, as well as a classroom observation

Does this student currently have a 504 Plan, IEP, ISP or other educational plan?*

Yes No

A copy of current (within the last 3 years) psycho-educational testing MUST be provided to Mount St. Mary High School to complete the application for admissions. Psycho-educational testing can be completed through private testing or through an IEP with your public school district.

Please upload current IEP and psychoeducational testing documents

If file size is too large, please email documents to Diane Wilson, Director of Admissions, at dwilson@mountstmary.org

Max file size: 10 MB

Date of last (or upcoming) psychoeducational testing performed by a licensed psychologist or psychiatrist:

Do you have any additional information about this student that would help in his/her academic or social success in high school?

Cornerstone Inclusion Program Homework and Classwork Agreement

We understand that for our child to be successful in the Cornerstone Inclusion Program, strong support from home is needed in the areas of academic, extracurricular activities, and social communication. We agree to provide the following support to our student:

1. There will be homework every night. I agree to work with my student to make sure his/her homework assignments are completed and returned to the teacher on time.

2. I will review my student’s agenda, PowerSchool, Google Classroom, Schoology, etc every night to ensure all assignments and projects are completed on time.

3. To ensure that my student has all of the supplies and books for each class. If a book is needed in audio format, I understand I need to provide that also.

4. I will not do my students homework for him/her. I understand I am there to offer guidance, support, review for tests and quizzes.

5. If there is something that needs to be clarified or discussed, I will reach out to my student’s teachers and understand that I may not contact the Student Scholar that aids my student during the school day.

6. I understand that if I do not support my student at home, then my student may be asked to leave the program..

7. I understand that the students who are accepted into the Cornerstone Inclusion Program must enroll as a Freshman.

8. I understand that the students in the Cornerstone Inclusion Program will receive a “Certificate of Completion” and not a diploma.

Cornerstone Inclusion Program Statement of Understanding*

I herby agree to the above understanding and know that my child will receive a "Certificate of Completion" not a high school diploma.

Student Response Questions

Tell us about yourself, special interests, hobbies, church activities, or favorite things you like to do.required

What are your favorite subjects in school and why?required

List your top 3-5 favorite activities and explain why they are important to you.required

Teacher Recommendation

Please list the contact information of your student's Special Education Teacher at their current school to receive a recommendation form that will be completed and sent to Mount St. Mary Catholic High School.

Name: required

Title or Position:required

Email Address:required

Release of Records

Mount St. Mary Catholic High School will request the following documents from your student's current school:

Copy of report card (6th grade, 7th grade, first semester of 8th grade)
MAP Testing Report
Attendance Records (7th grade, first semester of 8th grade)
Immunization Records
Birth Certificate
Behavioral Observations
ISP/IEP/Psychoeducational Testing Record
Relevant medical information

Release of Records Permission*

I herby give permission for my child's current school to release the above information requested by Mount St. Mary Catholic High School.

Please send a confirmation email to the address below:

Please provide an email address where we can send a link to your current form.

Email Address :