Application Form - STEM-Summer Enrichment Program (STEM-SEP) 1

Student Information

Full Name

Date of birth

Gender

Man

Woman

Nonbinary

Other

Prefer not to say

Race / Ethnicity

Other (Please Specify)

Phone number

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

How did you hear about STEM-SEP?

Have you attended similar programs before?

Yes

If Yes, provide details

Educational Information

High school name

Current high school overall GPA

Grade level in spring

Other Specify

Science (Math, physics, biology, etc.) courses & year taken in high school

Intended major or area of interest in college (if known)

Educational attainment of parents/guardians 1

Educational attainment of parents/guardians 2

Activities and Awards

Extracurricular activities in school (example – sports, choir, school newspaper)

Awards and/or honors (example – placing in academic competition, honor roll, etc.)

Community service activities (example – volunteering with homeless, tutoring younger students, etc.)

Short essay

In 300 to 500 words, explain why you are interested in attending this workshop.

I understand that, if selected, I am required to attend all workshop sessions

I hereby verify that all the information that I have provided on this application is true and accurate. My signature gives permission for the project personnel to review any academic records and any information pertaining to my eligibility for this workshop.

Signature of student

Sign above

Name of parent/guardian

Signature of parent/guardian

Sign above