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Student Application Base Template

Application Deadline: [input Date]

Thank you for your interest in Breakthrough! Students and parents should carefully read all of the information below. PROGRAM RUNS FROM JUNE 9th to JULY 18th, 2025. ONLY 3 ABSENCES ARE ALLOWED DURING THE 6 WEEK PROGRAM. Please do not apply if your child cannot attend all 6 weeks.

Breakthrough Louisville is a free, 6-week summer academic program for middle school students (rising 6th - 9th graders) in Jefferson County, KY. We have a dual mission of building academic confidence and introducing college students to the teaching profession.

Breakthrough Louisville is committed to selecting a class of students representative of their community.

Selection Timeline for Summer: Completed applications need to be submitted (at the latest) by May 1. Applications received by that date will be given preference. After May 1, if openings exist, candidates will be considered.

Online Application and Parent / Guardian Packet Due Date: May 1
Applications Reviewed by Breakthrough Staff: Applications will be reviewed as they are received and families notified as soon as all materials are verified and student is deemed a good fit for our program. We cannot accept all students.
Interviews: TBD
Decision Letters Mailed: Families will be notified by email as soon as application is completed and verified.

Breakthrough Site Information: Our program is held on the Louisville Collegiate Campus (2427 Glenmary Ave., 40204). The school donates its space to Breakthrough Louisville during the summer.

Student Section: We are interested in getting to know each student who applies to Breakthrough so this section should ONLY BE COMPLETED BY THE STUDENT. If you have any questions as you complete this portion of the application, please reach out to an adult.

Student Contact Information

First Name:

Middle Name:

Last Name:

Preferred Name/ Nickname:

Student Email Address:

Home Phone:

Cell Phone:

Gender:

Gender Specify:

Birth Date:

Birth Country:

Home Address Street:

Home Address City:

Home Address State:

Home Address Zip Code:

Student Language(s)

What language do you speak most of the time, at home?

Do you speak any other language(s) at home?

What is the second most common language you speak at home?

Are there any other language(s) you speak at home?

Select any other language(s) you speak at home:

Arabic	Bengali	Cantonese/Yue	Creole
English	French	German	Hindi
Hmong	Italian	Japanese	Javanese
Karen	Korean	Malay	Mandarin/Chinese
Marathi	Portuguese	Punjabi	Russian
Spanish	Tamil	Telugu	Turkish
Urdu	Vietnamese	Wu	Language Not Listed

Teacher or Other Recommenders

Breakthrough requires two recommendations as part of the application process. Please list the teachers who will provide your recommendations. Your parent / guardian will be asked to provide their email addresses in the parent section of the application.

Recommender 1:

Please provide the teacher's full name.

Recommender 2:

Please provide the teacher's full name.

Breakthrough History

How did you hear about Breakthrough?

Breakthrough presentationBreakthrough staff memberFamily connectionTeacher/School staff memberBreakthrough studentOtherIf more than one, choose the option that was most influential in applying for Breakthrough

Other - please explain:

Please provide details on how you heard about Breakthrough:

Names of family members, teachers, etc.

School Information

Current Grade:

How difficult is your current school work?

Your student School ID number (if known):

ID number issued to you by the school or district.

Affiliate Instruction

For all short answer and essay questions you need to populate the question(s) below AND in the Connector in order for the record in Salesforce to show the question they are answering. These instructions are for your use and will be hidden from applicants.

Short Answer Questions: Please answer all of the questions below using at least 2 sentences. We want to see your best work! You may copy/paste from a Word document if you like.

1. Why do you want to attend Breakthrough Louisville this Summer?

Student Short Response Answer #1

Your answer is required in order to submit.

2. Name 3 things you like about school and why.

Student Short Response Answer #2

Your answer is required in order to submit.

3. Identify 2 challenges you face in school with detail.

Student Short Response Answer #3

Your answer is required in order to submit.

Essay: Please answer the questions below using 250 words or less. We want to see your best work! You may copy/paste from a Word document if you like.

1. What is something you want to learn about this summer? Also, describe something unique about yourself.

Student Essay Answer #1

Your answer is required in order to submit.

2. What careers are you interested in when you grow up? Why do they interest you? What steps can you take to get there? How important is doing well in school necessary to achieve these goals?

Student Essay Answer #2

Your answer is required in order to submit.

Family Section: This section of the application should ONLY BE COMPLETED BY A PARENT / GUARDIAN.

Breakthrough Louisville is only successful if your student can attend for the full 6-weeks. Please apply only if you know your child will be on campus every weekday during our 6-week session.

Parent / Guardian Information

First Name:

Last Name:

Gender:

Gender Specify:

Birth Country:

Home Address Street:

Home Address City:

Home Address State:

Home Address Zip Code:

My address is the same as the student:

Email Address:

Home Phone:

Cell Phone:

Work Phone:

Preferred means of contact:

Please select the best day(s) to contact you:

MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Please select the best time(s) to contact you:

MorningDaytimeEvening

Employment History

Employment status:

Education History

Does your student qualify as a first-generation college student (i.e. Neither parent has a 4-year degree from the US)?

A first-generation student means BOTH parents did not complete a 4-year college or university degree (or higher). If a degree was obtained from a country other than the United States, a student qualifies as a first-generation student.

Highest level of education completed:

Home Language(s)

What language do you primarily speak at home?

Is there a secondary language you speak at home?

What secondary language do you speak at home?

Are there any other language(s) you speak at home?

What additional language(s) do you speak at home? Select all that apply.

Arabic	Bengali	Cantonese/Yue	Creole
English	French	German	Hindi
Hmong	Italian	Japanese	Javanese
Korean	Malay	Mandarin/Chinese	Marathi
Portuguese	Punjabi	Russian	Spanish
Tamil	Telugu	Turkish	Urdu
Vietnamese	Wu	Language Not Listed

How comfortable are you with English?

Would you need documents and communication to be translated for you?

Relationship Details

Is the student being raised in a single parent household?

What is your relationship to the student?

Do you have a spouse or partner who lives in the same household as you and your student?

What is your spouse/partner's relationship to the student?

Is there any other adult(s) involved in the student's upbringing or living in your home that we should be in contact with?

Please provide details on other adult(s):

Ex: Name, relationship, contact information, etc.

How much of the time does your student live with you?

Does the student receive additional financial support from another parent or guardian?

Where does the student live when not living with you?

Please explain any additional things to know about the student's family or family structure below:

I would like to enter information for a second Parent/Guardian:

Parent / Guardian #2 Contact Information

Does Parent/Guardian #2 live in the same household as Parent/Guardian #1?

I am only comfortable providing basic contact information on behalf of 'Parent / Guardian #2'.

First Name:

Last Name:

Gender:

Gender Specify:

Birth Country:

Home Address Street:

Home Address City:

Home Address State:

Home Address Zip Code:

Home Phone:

Relationship Details

What is their relationship to the student?

How much of the time does the student live with them?

Cell Phone:

Work Phone:

Email Address:

Preferred means of contact:

Please select the best day(s) to contact them:

MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Please select the best time(s) to contact them:

MorningDaytimeEvening

Employment History

Employment status:

Education History

Their highest level of education completed:

Home Language(s)

What language is primarily spoken in their home?

Is there a secondary language spoken at their home?

What secondary language do they speak at their home?

Are there any other language(s) they speak at home?

What additional language(s) do they speak at home? Select all that apply.

Arabic	Bengali	Cantonese/Yue	Creole
English	French	German	Hindi
Hmong	Italian	Japanese	Javanese
Karen	Korean	Malay	Mandarin/Chinese
Marathi	Portuguese	Punjabi	Russian
Spanish	Tamil	Telugu	Turkish
Urdu	Vietnamese	Wu	Language Not Listed

How comfortable are they with English?

Would they need documents and communication to be translated?

Family Section: This section of the application should ONLY BE COMPLETED BY A PARENT / GUARDIAN. Breakthrough will review all information carefully, confidentially, and holistically.

Breakthrough History

How did you hear about Breakthrough?

Breakthrough presentationBreakthrough staff memberFamily connectionTeacherBreakthrough studentOtherSelect all that apply.

Other - please explain:

Please provide details on how you heard about Breakthrough:

Names of family members, teachers, etc.

Do you have any other children or relatives in the program?

What is their relationship to the student applicant?

Please provide details of the Breakthrough student(s): name(s), relationship type(s), Breakthrough site(s), and their current grade level(s):

Family Background

Is your monthly income fixed or flexible?

What was your ANNUAL pre-tax household income last year:

How many people living in your household are under the age of 18?

How many people in your household are 18 years of age or older?

Has anything happened in the last year that has impacted the accuracy of the information provided on your current financial situation?

Family Section: This section of the application should ONLY BE COMPLETED BY A PARENT / GUARDIAN. Breakthrough will review all information carefully, confidentially, and holistically.

Student Background

Does your student qualify for Free or Reduced Price Lunch?

If you are unsure if your student qualifies, visit this website to calculate free or reduced price lunch status: https://reports.educateiowa.gov/ICAVES/Home/Calculator (copy and paste into a new browser).

Is your student Hispanic or Latinx?

Which of the following choices describe your student's race? Select all that apply.

Alaska Native American IndianAsian or Asian AmericanBlack or African AmericanMiddle Eastern or North AfricanMultiracialNative HawaiianPacific IslanderWhite Other Race, not listedDecline to State

Please specify student's country/ies of origin:

Hold down the Ctrl button to choose more than one.

Please list or describe any other communities your student identifies with:

Can be specific ethnicity (Hmong, Chinese, Nigerian), religious affiliation (Muslim, Jewish, Jain), or any other community your student identifies with.

How will your student get to/from Breakthrough?

Other transport:

Does your student currently participate in any other programs or activities?

Examples: Sports, Avid, Boys and Girls Club, Religious Activities, etc.

Please describe your student's other commitment(s). How many hours per week does your student dedicate to each activity and how flexible are these commitments?

Do you foresee any conflicts with the dates of the program?

Please explain conflicts/concerns:

To ensure that your child receives the consideration, support and encouragement they need while in Breakthrough, please share any educational support/services your student has or is currently receiving. Please select all that apply.

None	EL	IEP
504	Accommodation plan	RSP
Other

If applicable (i.e. speech therapy, extra tutoring, medication, any accomodations, IEP, 504 Accomodation plans, RSP, etc.)

Please describe educational support/ services:

Breakthrough is a rigorous 6-week academic commitment. How will you help your student fulfill this commitment? Please explain:

Please upload a student photo (optional):

Family Section: This section of the application should ONLY BE COMPLETED BY A PARENT / GUARDIAN. Breakthrough will review all information carefully, confidentially, and holistically.

Affiliate Instruction

For all short answer and/or essay questions you need to populate the question(s) below AND in the Connector in order for the record in Salesforce to show the question they are answering. These instructions are for your use and will be hidden from applicants.

Short Answer Questions: Help us get to know your student by responding to the questions below. You may copy/paste from a Word document if you like.

1. Why do you want your student(s) involved in Breakthrough this Summer?

Parent Short Response Answer #1

Your answer is required in order to submit.

2. Please provide any information you believe would be useful for our staff to know in helping your child succeed.

Parent Short Response Answer #2

Your answer is required in order to submit.

3. If your child has a specific interest in something we could encourage, please note below.

Parent Short Response Answer #3

Your answer is required in order to submit.

Student School Information

Name of student's current school:

Other School:

Will the student be attending the same school next year?

Student's new school name:

Please list the school counselor or registrar at your student's school:

Recommendation Information: Breakthrough requires two recommendations as part of the application process. Your student has already provided names, please provide the email address and we will contact these recommenders directly via email.

Recommender 1

1. Recommender's Name:

If this name is incorrect or mispelled, please correct under the student section on page 3 of this form.

1a. Recommender's Email:

Recommender 2

2. Recommender's Name:

If this name is incorrect or mispelled, please correct under the student section on page 3 of this form.

2a. Recommender's Email:

Student's Most Recent Report Card

Breakthrough Expectations

Breakthrough Louisville is a 6-week program that is only beneficial when the student can be there for the full program. If your child has conflicts that will not allow them to participate for the full 6 weeks, please do not apply. We can only accept 60 students and we want every student to have a chance at succeeding!

By checking the box below, you are acknowledging that you understand the expectations Breakthrough has for its students and families accepted into its program.

Please confirm your commitment by checking the box below.

I understand the expectations of Breakthrough

Your answer is required in order to submit.

Affiliate Application Record Type ID

This must have a "Default Value" populated with the Application Record Type ID for each affiliate as part of launch. This is found in Setup>Object Manager>Application>Record Types>Application>then get the ID from URL. Connector won't work until this is done.

It may take up to 1 minute for the application to process before you see the confirmation screen. Please do not hit submit a second time. Thank you for your patience!

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