Student Name:____________________________________________________
School:__________________________________________________________
 Do you know what you want to do after high school?
 Do you have a career in mind?
Do you know what jobs are available in SWFL?
 Do you know how you are going to pay for college or
technical school?
If you answered ‘I don’t know’ to any of these
questions…. Then you should apply for STAMP!
Student Name:____________________________________________________
School:__________________________________________________________
STUDENT ADVOCACY AND MENTORING PARTNERSHIP APPLICATION
STAMP was created to give eligible students the opportunity to achieve success by providing them
with resources and mentoring opportunities to help prepare the student for college, technical school,
or other post-high school training. Through mentoring and the help of the Foundation staff, we will
assist the student with exploring career opportunities, academic success, and we will provide various
resources for college and career preparation.
Resources offered will include, but not be limited to, one on one mentoring, group mentoring,
E-mentoring, career exploration workshops, automatic acceptance into STEM @ Work, financial aid
assistance, etc.
Checklist for Completed STAMP Application
Please check off that each piece of information is enclosed before submitting
application!
Incomplete and/or late applications will not be accepted.
Due Friday, May 12th to The Foundation for Lee Co. Public Schools.
STAMP Coordinators/Counselors may require earlier deadline.
___________Completed Application with ALL areas filled out and ALL forms signed.
____________ Recent federal income tax (1040, 1040A, 1040EZ) form for ALL wage earners in
the home; OR proof of receiving current unemployment or disability benefits.
(Students must be listed as a dependent on the front page of Form 1040, 1040A,
or 1040EZ.)
____________ Copy of previous month’s paystubs for all wage earners in the home.
____________ Two completed recommendation forms.
____________ Copy of ORIGINAL 9th grade report card. (Not a printout from
ParentLink)
Student Advocacy & Mentoring Partnership 2016-2017
Student Selection Criteria: All STAMP recipients must meet the following criteria:
 Must be a 9th grade student in a Lee County public school.
 Family income must be at or below the following:
o Effective July 1, 2016 to June 30th, 2017
Household Size
Annually
Monthly
Twice Per
Month
Every Two
Weeks
Weekly
1
2
3
4
5
6
7
8
For each add’l family
member, add
21,978
29,637
37,296
44,955
52,614
60,273
67,951
75,647
1,832
2,470
3,108
3,747
4,385
5,023
5,663
6,304
916
1,235
1,554
1,874
2,193
2,512
2,832
3,152
846
1,140
1,435
1,730
2,024
2,319
2,614
2,910
423
570
718
865
1,012
1,160
1,307
1,455
7,696
642
321
296
148
Reminder: Total income before taxes, social security, health benefits, union dues,
or other deductions must be reported.
Scholarship Application
Deadline: Friday, May 12th
No late and/or incomplete applications will be accepted.
Use black or blue ink only, no pencil.
SECTION A: STUDENT IDENTIFICATION INFORMATION
Student’s full name: _____________________
Student ID#: _____________________
Social Security #
Grade:__________ Date of Birth:__________
: _____________________
Are you a US Citizen? Yes
No
Gender: Male_____ Female _____
Ethnicity:
Hispanic
Race:
Non-Hispanic
Black/African America
Asian
American Indian/Alaska Native
White
Hawaiian/Native Pacific Islander
Home Address:
___________________________________________________________
City:
State:
Zip: ________
Student Cell Phone Number:______________________ Student Email:________________________
Has the student participated, or currently participates, in any of the following programs (Check all that apply)
Jack and Jill Children’s Center _____
Boys and Girls Club _____
Big Brothers, Big Sisters _____
Women of Tomorrow _____
Girl Scouts _____
Boy Scouts ______
Others______________________________________________
Has the student ever applied for any other FLCPS programs? _____ Take Stock in Children
_____ STEM @ Work
SECTION B: Household Information
Applicant lives with:
Mother
Grandfather
Father
Guardian
Grandmother
Number of brothers: _____
Step Mother
Stepfather
Other _____________________________
Number of sisters: _____
Please list all persons living in the home other than student/applicant:
Name
Age
Relationship to Student
Last Grade Completed
Relationship to Student
Last Grade Completed
Independent siblings living outside the home
Name
Age
SECTION C: Parent/Guardian Information
Is either parent self-employed?
Yes
No
If yes, business name:______________________________
Parent/Guardian’s Current Information (Father’s Section)
Name:_______________________________________
(Last)
(First)
Date of Birth: _____________
(MI)
Address:______________________________________________________________
Phone Number: ________________
Email:________________________________
Employer: __________________________________ Social Security #: __________________
Occupation and Employer’s Address:________________________________________________
Number of years with current employer: ________________
Check here if father is currently unemployed
Monthly Salary:___________
Check here if father is currently looking for a job
If father is currently unemployed and not looking for a job, please explain why here:
_______________________________________________________________________________________
Parent/Guardian’s Current Information (Mother’s Section)
Name:_______________________________________
(Last)
(First)
Date of Birth: _____________
(MI)
Address:______________________________________________________________
Phone Number: ________________
Email:________________________________
Employer: __________________________________ Social Security #: __________________
Occupation and Employer’s Address:________________________________________________
Number of years with current employer: ________________
Check here if mother is currently unemployed
Monthly Salary:___________
Check here if mother is currently looking for a job
If father is currently unemployed and not looking for a job, please explain why here:
________________________________________________________________________
SECTION D: Financial Information
What is the entire monthly household income? $___________(before taxes)
*Have you received any of the following in the past 6 months?
___ Welfare Transition (WAGES) assistance
___ Food Stamps
___ TANF dollars
___ Medicaid
___ Social Security Income (SSI)
___ Social Security Disability Income (SSD)
___ Other (please explain): __________________________________________________________
* Please attach RECENT government letters/documentation for any of the above.
Do you own your own home? No____ Yes____ Purchase Price $___________
If yes, what is amount of your monthly payment? $___________
Do you rent? No____ Yes____
If yes, what is amount of your monthly payment? $___________
Is this payment made to a friend or relative? Yes____ No____
****Please attach your most recent federal income tax statement (1040, 1040A,
1040EZ) form for all Wage Earners in the Home; OR proof of receiving current
unemployment or disability benefits. (Student must be listed as a dependent on the front page
of Form 1040, 1040A, or 1040EZ)****
SECTION E : PARENT STATEMENT
To be completed by the PARENT(S) or GUARDIAN.
Please use blue or black ink, no pencil and print legibly. Attach additional sheets if needed.
Describe your child. What are his/her strengths? Weaknesses? Why should your child be chosen
for this program? What do you see as your responsibility in your child’s educational goals?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Single parent
Bus ride more than 30 minutes to school
Incarcerated parent
English not spoken in home
Deceased parent
Migrant worker
Absent parent (no contact or support)
Loss of employment
Poor relations between biological parents
DCF involvement
Family has received TANF benefit from State of Florida
Extended family in home
Home is in foreclosure
Homeless or living with extended
family or friends
Serious illness in household
Extended family raising student
Disabled student or family member
Student applicant is a teen parent
Parent was a teen parent
Student is/was in foster care
________
If any of the above are checked, please explain:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Please briefly describe your home environment:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
SECTION F: STUDENT STATEMENT
To be completed by the student ONLY.
Please use blue or black ink, no pencil and print legibly. You may attach additional sheets if needed.
An important part of this program is partnering you with experiences and mentoring relationships that
our community can offer. What types of assistance and resources would benefit you and why?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
___________________________________________________________________________________
What is your career goal(s) and how do you plan on achieving this?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
___________________________________________________________________________________
Please list all clubs, activities, sports, etc. that you are involved in.
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Have you ever struggled in a class or social situation? How did you overcome it?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_____________________________________________________________________________________
PLEASE PROVIDE TWO (2) LETTERS OF RECOMMENDATION
Please attach 2 letters of recommendation from coaches, scout leaders, church members, counselors, or
teachers (NOT parent, guardian, or other family member).
Letters should include an indication of character and values. We want to know “who” you are from their
point of view!
STUDENT AND PARENT AGREEMENT:
I understand that the information contained in this application is accurate and will be shared with the STAMP
student selection committee. I understand that this contract replaces any previous contracts that I have with
The Foundation for Lee County Public Schools, Inc. I understand that the information that I have provided in
this application will be verified by program staff and that any false information in this application may result in
my child being ineligible and being removed from the program. I have read the program requirements and
approve of my child’s participation in having a mentor(s) and attending activities, workshops, field trips, etc. I
understand that my involvement as parent(s) or guardian is crucial to my child’s success in this program. I
assume full responsibility for my child’s conduct and I will not hold The Foundation for Lee County Public
Schools, Inc. or other related parties liable for accidents that may occur as a result of my participation or my
child’s participation in the program.
________________________
Student Signature
_________ _________________________
Date
Parent/Guardian Signature
_______
Date
STUDENT INTERVIEW AGREEMENT:
I understand that prior to my child being considered for this program, they will be interviewed by The
Foundation for Lee County Public Schools staff and that the outcome of that interview may affect whether or
not my child will be accepted into STAMP. If my child refuses to be interviewed, I understand that he/she will
not be selected for STAMP.
________________________
Student Signature
_________ _________________________
Date
Parent/Guardian Signature
_______
Date
STUDENT PLEDGE
I have never been convicted of a crime nor do I take drugs. I agree to stay crime and drug free! I agree
to meet with my assigned mentor regularly, and maintain at least a 2.5 GPA in school. I also agree to
have good behavior and attendance!
_____________________________________
Student Signature
___________________
Date