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BEFORE YOU BEGIN YOUR APPLICATION HERE’S WHAT TO KNOW:

Breakthrough Scholars Are:

Academically Motivated with a mostly B’s and above
Enrolled in 4th or 5th Grade in Public, Charter, Private, or Home School
Can attend both school year and summer programming

Meet 1 of the following 4:

Family income qualifies for free/reduced lunch
First generation in their family to attend college in the US
Single-parent household
Primary language other than English

Have Ready:

Math Teacher Name
Math Teacher Email
Reading/ELA Teacher Name
Reading/ELA Teacher Email
Completed Mutual Exchange Form (Document Upload)
Grades for Current Year (Document Upload)
Previous Year Transcripts (Document Upload)
FAST Scores or Equivalent Standardized Testing (Document Upload)
Photograph of applicant

PLEASE NOTE: You do not have to complete the entire application at one time.

There are buttons at the top and bottom of each page that allow you to save your progress and resume later, if needed.

For additional assistance, please contact us at 305.646.7210.

¿Prefieres ver esta página en español?

Usa la función de traducción del navegador: haz clic derecho en la página y selecciona "Traducir al español".

Èske ou ta pito wè paj sa a an kreyòl?

Si wi: klike sou paj la ak bouton dwat souri la epi chwazi "Tradui an kreyòl".

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:

Email Address:

Home Phone:

Cell Phone:

Gender:

Sex:

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

School Information

Current Grade:

How difficult is your current school work?

Your student School ID number:

ID number issued to you by the school or district.

School County Text

Student School Information

Name of student's current school (Miami-Dade):

Name of student's current school (Broward)

Name of student's current school (Palm Beach):

What county do you attend school in?

Name of Student's Current School:

Select your County, then type your school and select from the list. If your current school is not listed, select "Other - Not Listed."

Other - Not Listed value

Name of current 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. Please list the teachers who will provide your recommendations. Please provide the name and email address and we will contact these recommenders directly via email.

Recommender 1

Name of Recommender 1:

Please provide the teacher's full name.

1. Recommender's Name:

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

Recommender 1 Email:

Recommender 2

Name of Recommender 2:

Please provide the teacher's full name.

2. Recommender's Name:

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

Recommender 2 Email:

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. What are your future goals? How is going to college going to help you reach these goals? (Provide your answer in at least two complete sentences).

Student Short Response Answer #1

Your answer is required in order to submit.

2. Name someone you especially admire and why? (Provide your answer in at least two complete sentences).

Student Short Response Answer #2

Your answer is required in order to submit.

FAMILY SECTION: This section of the application should BE COMPLETED BY A PARENT / GUARDIAN.

Parent / Guardian Information - Información de contacto del padre/ tutor - Infomasyon Paran/Responsab

First Name:

Last Name:

Gender:

Gender Specify:

Birth Country:

Home Address Street:

Home Address City:

Home Address State:

Home Address Zip Code:

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::

MorningDaytime

Evening

Employment History

Employment status:

Employer name:

Education History

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

Highest level of education completed by Parent-Guardian 1:

Country where degree was awarded:

Name of Institution:

Graduation Year/Last Year Attended:

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 the 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 the 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 contactu:

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

MondayTuesdayWednesdayThursdayFridaySaturdaySunday

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

MorningDaytimeEvening

Employment History

Employment status:

Employer name:

Education History

Highest level of education completed by Parent-Guardian 2:

Country of Bachelor's degree:

Name of Institution:

Graduation Year/Last Year Attended:

Home Language

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 BE COMPLETED BY A PARENT / GUARDIAN. Breakthrough will review all information carefully, confidentially, and holistically.

Breakthrough History

How did you hear about Breakthrough?

Breakthrough presentation Breakthrough 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 is your household's annual total income before taxes?

Does the student qualify for Free or Reduced Price Lunch?

If you are unsure if your student qualifies, please select THIS LINK to calculate free or reduced price lunch status.

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

Please list the names and ages of any children under 18 in the household:

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

Please upload your 1040 (optional):

Form 1040 is an IRS tax form used for personal federal income tax returns filed by United States residents. The form calculates the total taxable income of the taxpayer. IRS 1040 form can be found here : https://www.irs.gov/pub/irs-pdf/f1040.pdf (copy and paste into a new browser)

We use the income and household information above to better understand the needs of our applicants. Please provide any additional personal or financial information you think would help us more accurately determine need for our program.

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

Student Background

Is the student Hispanic or Latinx?

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

Alaska NativeAmerican IndianAsian or Asian AmericanBlack or African AmericanMiddle Eastern or North AfricanMultiracialNative HawaiianPacific IslanderWhiteOther 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 the 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 the student get to/from Breakthrough?

Other transport:

Breakthrough provides students with access to public transportation, but students do travel to and from the program alone. Would you allow the student to travel alone on public transportation/El programa de Breakthrough proporciona acceso a transportación público pero los estudiantes viajan durante y después del programa solos. Le da permiso a su hijo/hija a viajar solo/sola usando transportación público/Breakthrough bay elèv yo aksè nan transpò piblik, men elèv yo souvan vwayaje ale ak soti nan pwogram nan poukont yo. Èske w ta pèmèt pitit ou a vwayaje pou kont li nan transpò piblik:

During School Year in the evenings (6:00 pm)?/¿Durante el año escolar en las tardes (6:00 pm)?/Trong năm học vào buổi tối (6:00 PM)?During Summers?/¿Durante el verano?/Trong mù hè?I do not want my child to travel alone on public transit; No me gusta que mi hijo/hija viaje solo/sola usando transportación público; Tôi không muốn con tôi đi một mình trên vận chuyển công cộng.Check all that apply./Marque todo lo que corresponda./Tcheke tout sa ki aplike.

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

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

Please describe the 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 the student receives the consideration, support and encouragement they need while in Breakthrough, please share any educational support/services the 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:

Breakthrment? Please explain: - Breakthrough es un compromiso académico de 8 años. ¿Cómo ayudará a su estudiante a cumplir este compromiso? Por favor escriba al menos dos oraciones completas: - Breakthrough se yon angajman akademik solid pou 8 ane. Ki jan w ap ede elèv ou a akonpli angajman sa a? Tanpri eksplike:

FAMILY SECTION: This section of the application should 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. Tell us why YOU, as the parent(s)/guardian(s) want to be a part of the Breakthrough community and why you think it is important for this student to attend Breakthrough Miami.

Parent/Guardian Short Response Answer #1

Your answer is required in order to submit.

Your answer is required in order to submit./Se requiere su respuesta para poder enviar./Repons ou obligatwa pou w ka soumèt.

Site Assignment:

Based on your zip code you will be considered for:

I want to be considered for a different site

(check the box to be considered for an alternate site)

I would rather be considered for:

Please provide a reason for why you would like to apply to a different site:

Document Upload

Please upload the following documents in support of your application.

Photo Of The Applicant:

Mutual Exchange Of Information: Miami-Dade Consent Form Broward Authorization for Release Palm Beach Authorization Form (Spanish; Creole)

Student Grades for Current Year:

Student Grades for Previous Year:

Most recent FAST Scores/Standardized Test Scores:

Breakthrough Expectations

Breakthrough Miami is an academic-enrichment program that requires an eight-year commitment. We expect students to participate and engage in all summer and school year programs throughout middle and high school. Breakthrough Miami expects 100% of its students to graduate from high school and enter college, university, or a post-secondary educational opportunity.

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

Please confirm your commitment by checking the box below

I understand the expectations of Breakthrough Miami.Your answer is required in order to submit.

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!

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.

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