Dear Parent and Student,
Let me introduce you to our program which has provided academic services to the
community for 30 years. The College of Staten Island Liberty Partnerships Program (CSI LPP).
Liberty believes that each student has the ability to achieve their goals when families, schools,
and communities participate, and our goal is ensuring that all of our students achieve academic
success, graduate high school, and enter their post-secondary careers prepared.
The Liberty Partnerships Program was funded on July 1, 1989 by New York State Higher
Education Department, K-16 Initiatives and Access programs. It is a collaborative college-
school-community based project which provides a broad range of instructional, enrichment, and
support services to at-risk students and their families. The main purpose of the program is to
improve the academic, social, and life skills of our students by providing supports and services
that ensure they advance to post-secondary education and meaningful employment. The project
represents collaboration between the College of Staten Island, Staten Island High Schools, and
various community partners. These productive partnerships help to strengthen the relationships
between students, teachers, parents, administrators, caseworkers, community organizers, and
civic and business leaders. The program fosters continuing communication among members of
various institutions, groups, agencies, and bureaucratic systems that influence the lives and
education of our students.
Liberty is a comprehensive program which serves the needs of students in grades 5 through 12 and
serves more than 300 students annually. Liberty provides services for students attending the
following high schools: Curtis High School, Port Richmond High School, Susan Wagner High
School, and Ralph R. McKee Career and Technical High School. We are excited to be
joining the school communities at one elementary school, P.S. 78 – The Stapleton Lighthouse
Community School, and one intermediate school, I.S. 49 – Bertha A. Dreyfus. All LPP
students are eligible and encouraged to attend our summer enrichment program, Dreamer’s Academy,
in which students attend and participate in workshops, taught by certified teachers and instructors.
Our program is comprised of the following interrelated features and elements:
1. Our well-rounded college students serve as Academic Coaches to work with students under
the joint supervision of both school and CSI staff. They provide specific tutorial services,
mentoring, academic goal setting, and referrals in individual and small group tutoring and
counseling sessions throughout the school day.
2. Our staff members are trained in youth development principles, social emotional
learning, Covey’s Seven Habits of Highly Effective People/Teens, sports-based youth
development, among others. They serve as role models, advocates, and mentors to all LPP
students.
3. LPP seeks to provide increased support services and referrals to all of its families through
the work of the LPP Parent Leadership Team. This allows all LPP families to participate in
events, activities, information sessions, and workshops. In addition, parents can take
advantage of parent-to-parent self-help support systems, educational, and employment
support services, including relevant referrals.
4. Our activities include a wide range of social, emotional, cultural, educational, college, and
career supports. Students have the opportunity to take advantage of our technologically
advanced campus and its facilities. In addition, all LPP students are encouraged to attend
trips throughout the city, upstate, and out-of-state. The focus of all of our activities is to
develop, enhance, and refine the academic and social skills of our students through both
individual and group experiences.
Thank you so much for considering our program and if you have any questions or concerns,
please feel free to contact us. For more information on our program, please visit
www.csi.cuny.edu/lpp
.
Sincerely,
Shawn D. Landry, LMSW
Program Director
CSI Liberty Partnerships Program
2800 Victory Blvd. 2A-204 Staten
Island, NY 10314
Tel: 718-982-2157
Fax: 718-982-2353
Shawn.Landry@csi.cuny.edu
STUDENT REFERRAL FORM
Gender: (Please check)
□ Male □ Female
Ethnicity: (Please check)
□ Black, non-Hispanic □ White, non-Hispanic □ Asian/Pacific Islander
□ Hispanic □ American Indian/ Alaskan Native □ Other
Please Explain if Other:
Parent / Guardian
Last Name:
First Name:
Relationship: Telephone(s): Home:
Address: Work:
Apt. # Cell:
Email:
Student Information
Last name: First Name:
/
OSIS #: Student ID:
Address: School: Grade:
Apt.
Rank in class: Grade average:
City: _ State:
Guidance Counselor_
Zip code: Regent Test Scores – (specify test scores)
College of Staten Island City
University of New York
Liberty Partnerships Program Student
Contract
I understand that as a Liberty Partnerships Program student, I will be
invested in my academic success. My responsibilities include: actively taking part in a S.M.A.R.T. goal
plan that represents my vision of where I want to go and working on the path to get there. I am willing
to participate fully in the Liberty Partnerships Program; therefore, I agree to set up an Academic
Achievement Plan with my assigned intern and work with the intern to achieve my goals. Together with
the Liberty Partnerships Program my priorities include agreement to the following:
1. I will attend all tutoring and counseling sessions, and any other activities necessary to ensure
my academic success. Tutoring and counseling sessions will include periodic evaluation of
my progress, which will enable me to make any necessary corrections in my S.M.A.R.T. goal
plan to meet my goals and objectives.
2. I will attend a variety of the enrichment activities which will be held throughout the year.
3. I will participate in the Summer Program unless I am enrolled in summer school. If I am
enrolled in summer school, I will notify the Liberty Partnerships Program.
4. I will attend a minimum of 4 workshops per term.
5. I agree to follow the rules of both the Liberty Partnerships Program and The College of Staten
Island.
6. I will respect and treat program staff and my peers in an appropriate manner.
7. I will attend Saturday programs (contingent on funding).
8. I will submit to program staff all required documents (permission slips, etc.) in a timely
manner.
9. I understand that my parent(s) / guardian(s) are partners in my educational plan.
I further understand in order to participate in the Liberty Partnerships Program, I agree to all of the
above conditions and rules.
Student’s Signature Date Parent’s Signature Date
Address Telephone – Home
Telephone – Cell
Email Address
Referral Information
Referral Source:
Eligibility Factors (Check all that apply) Interventions Needed
Reason / Particulars (Brief Description):
Recommendations:
Intern:
Signature Print
Date:
Liaison: ______________________
Signature Print
Certification of Eligibility
Date:
I (Program Director / or designee), certify that this student is
eligible to participate in Liberty Partnerships Programs.
Signature: Title: Date: ___________
□ Unsatisfactory academic performance
□ Truancy
□ Behavior/Discipline Problems
□ Family/Peers have history of dropping out
school
□ Negative change in family circumstances
history of child abuse or neglect
□
Homeless/Residence in a shelter or foster
care
□ History of substance abuse
□ Limited English Proficiency
□ Teenaged pregnancy and / or Parenting
□ Negative Peer Pressure
□
PINS/Probation
□ Social/Emotional
□ Other_
□ Tutoring:
□ Subject(s)
□ Mentor
□ After School Program
□ Counseling
□ Home Visits
□ Other:
Liberty Partnerships Program Basic Student Assessment
Educational:
School__________________________________________________________Grade level _____
Expected graduation date
Does the student have an IEP? Yes or No (Circle One)
Does the student have resource room?
Social:
Is the student involved in extracurricular activities? _____
If so, what are they?________________________________
Who lives with the student and how old are they?
_________________________________________________
Legal:
Is the student currently a Person in Need of Supervision
(PINS) ?
If so, please provide probation officer’s contact information
(Name and phone number):__________________________
_________________
Has the student ever been arrested? ________ if so, was a
charge issued? _____ was the student convicted?
Please provide any additional details regarding the student’s
legal involvement:
_________________________________________________
_________________________________________________
________________________________________
Medical:
Does the student have health insurance? _____________
If yes, which provider?
Do you have a counselor or a therapist? ______
If so, what agency is the student involved with?
________________
Does the student have any medical conditions? _____
If so, please list them: ______________________________
Does the student currently take medication(s)? _____,
If so, please list them:
_____________________________________________
Has the student experimented with any substances? ______,
if so, please specify.
_____________________________________________
If the student answered “yes” to the previous question, how
often does the student use substances? Check One:
□ Daily
□ Weekly
□ Once
□ Weekends
□ Not sure
College of Staten Island
City University of New York
Liberty Partnerships Program
PARENT PERMISSION FORM
*All information is confidential and will not be distributed to any other office or program.
Social Security numbers are for Liberty Partnerships Program use only.
I (we) (Print name of Parent /Guardian)
request that my son/daughter (Print Name of Student)
participate in the Liberty Partnerships Program at_
(Print Name of School)
I (we) (Print name of Parent /Guardian)
authorize LPP Staff (Liberty Partnerships Program) to obtain and review school records,
and understand that records will be used in planning appropriate support services for my
son/daughter. I (we) understand that all information will be kept confidential. I understand
that the school will notify the Liberty Partnerships Program Director in a timely manner, if
any Liberty Partnership Program student is involved or charged with a crime; is seriously ill,
injured, pregnant or will be parenting; deceased; is promoted or put back a grade after
summer school or during the school year; is suspended for disciplinary reasons; is absent
from school for more than 5 consecutive days; drops out of the school for any reason, with
full explanation of a legitimate reason or whatever measures Liberty Partnerships program
interns or school staff took to discourage the student from dropping out.
Provide as requested by New York State Department of Education and Liberty Partnerships
Program staff: student transcripts, report cards, interim progress reports, examination results,
attendance and disciplinary files and any other record deemed necessary to meet student’s
needs and complete required reports. Provide the Liberty Partnerships Program with
graduation information including post-graduation plans. It is understood that Liberty
Partnerships Program staff will maintain confidentiality of personal information.
In addition, I
_authorize the use of photographs and images of and
by my daughter/son/ward to be used for publicity, promotion and fundraising purposes by
Liberty Partnerships Program. This permission expires at the time my child formally in writing
withdraws / Graduates from the Liberty Partnerships Program.
Signature of Parent/Guardian Date
This form must be signed by at least one parent/guardian who is legally responsible for
the child.
• Original to be kept in program student file.
• Copy to be kept on file at school to allow access to report cards and school records.
NYC
Department
of
Education
Chancellor's Regulation A-820
Attachment No. 1
Page 1
of
2
PARENT
'S
CONSENT
TO
RELEASE
OF
STUDENT
RECORDS
I,
_____________
__
_ _
_____
_,
am the
pa
re
nt/gu
ardian of print name
print name of student
date
of birth
who a
tt
end
s/
atte
nd
ed
th
e N
ew
Y
or
k City _
____
_ _
stud
ent
ID
#
Public S
ch
ools in
_____
__
___________
_
The last
sc
hool he/she attended year/
time
period
wa
s/
is
name
and
address
of
school
in
Borough
The stude
nt
is
under
th
e age of 18. (
Pl
ease
prov
ide any additional in
fo
rma
ti
on
th
at might
be
he
lpf
ul in loc
ati
ng
th
e
st
ud
e
nt
records (e.g., a
ddr
ess
or nam
e,
if
differ
ent
when he
/s
he
a
tt
ended)):.
_____________________
_
____
_
I,
give
consent
to the New
York
City
Department of
Education
to
release
my
child's
student
records
including
specific
records
to provide
as
requested
by
New
York
State
Department of
Education
and
College
of Staten Island, liberty
Partnerships
Program
staff.
The
following
records:
student transcripts, report
cards,
interim
progress
reports,
examination
results,
attendance
and
disciplinary
files
and
any
other
record
deemed
necessary
to meet student's
needs
and
complete required reports.
Provide
the Liberty
Partnerships
Program
with graduation information
includ
i
ng
post
-graduati
on
pl
ans.
It
is
understood that
College
of Staten
Island,
Liberty
Partnerships
Program
staff will maintain
confidentiality of
personal
information.
Provide name and addr
ess
of
person, agency, or co
mp
any:
College
of
Staten
Island,
Liberty
Partnerships
Program,
2800 Victory
Blvd
. Staten Island, New
York
10314.
Purpose
of
disclo
sure:
Th
e
ma
in purpo
se
of the program
is
to in
creas
e the motivation
and
ability of
the
st
udents
to
go
on
to
post-secondary ed
uca
t
ion
a
nd
meaningful employment.
The
pu
rpose
of this
d
isc
losure
is
to
assist
the stude
nt
s in th
ei
r
academ
ic so
ci
al
and emotional growth.
Signatu
re
of
pare
nt/guardian
date
