Last Name:
First Name:
Your HS OSI #:
Address:
Apt.#:
City:
State: --Select--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingGuamPuerto RicoNew BrunswickNewfoundlandAlbertaNorthwest TerritoriesNova ScotiaPrince Edward IslandQuebecSaskatchewanOntarioYukon TerritoryManitobaBritish ColumbiaOther
Postal/Zip Code:
Social Security #:
(enter format: xxx-dd-yyyy)

Student Cell Phone #:
E-Mail Address:
(Please print)

Date of Birth:
(enter format: xx-dd-yyyy)

Ethnicity: --Select--Black Non-HispanicHispanicWhite Non-HispanicAmerican IndianAsian-Pacific IslanderOther (Please specify)
Other:
(Please specify)

Citizenship:: --Select--US CitizenUS Permanent ResidentOther
Other:
(Please specify)

Student Gender:


Female     

Male     



Did you attend The STEM Institute before?:


No     

Yes     



If 'Yes' please enter when:
(Summer of xxyy)

Did you attend CollegeNOW before?:


No     

Yes     



If 'Yes' please enter when:
(Fall of xxyy and/or Spring of xxyy)

PARENT INFORMATION

Parent(s)/Guardian's Name:
Home/Cell Phone:
Work Phone:

EDUCATION
Current Grade:


9     

10     

11     

12     



Year Entered 9th Grade:
Graduation Date:
HS Average:
Math Average:
SAT Score Verbal:
SAT Score Math:
School Name:
Counselor Name:
School Address:
School City:
School State: --Select--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingGuamPuerto RicoNew BrunswickNewfoundlandAlbertaNorthwest TerritoriesNova ScotiaPrince Edward IslandQuebecSaskatchewanOntarioYukon TerritoryManitobaBritish ColumbiaOther
School Postal/Zip Code :
School Phone:
Phone Extension:
School E-Mail:
COURSES

Which GROUP are you applying for? Each group has two classes. Please check ONLY ONE. Applications with more than one group selected WILL NOT BE REVIEWED!

A. 1. Calculus I (elective HS credit) 2. Engineering Design 10100 (non-credit). *Pre-requisite: Pre-calculus or a grade of 90 or better in Math B

B. 1. Calculus I (elective HS credit) 2. College Critical Writing & Reading (1 elective HS credit). *Pre-requisite: Pre-calculus or a grade of 90 or better in Math B

C. 1. College Pre-Calculus (1 elective HS credit) 2. General College Physics (1 elective HS credit). *Pre-requisite: A grade of 90 or better in Advanced Algebra or its equivalent

D. 1. College Pre-Calculus (1 elective HS credit) 2. College Critical Writing & Reading (1 elective HS credit), Pre-requisite: Non-ESL students. *Pre-requisite: A grade of 90 or better in Advanced Algebra or its equivalent

E. 1. Advanced College Algebra & Trigonometry (1 elective HS credit) *Pre-requisite: A grade of 90 or better in general Algebra. 2. MUST select ONE course:

Classes E.:--Select--(A) General College Chemistry (1 elective HS credit). *Pre-requisite: HS average of 90 or better(B) College Critical Writing & Reading (1 elective HS credit). *Pre-requisite: Non-ESL students.

F. 1. Engineering 103 (Computer Methods) (Non-credit) 2. *Select ONLY ONE Research area: *Pre-requites: Calculus I (with a grade of C+ or better) or AP Calculus AB (with a score of 4 or better).

Classes F.:--Select--(A) Electrical Engineering(B) Civil Engineering(C) Mechanical Engineering(D) Science (BiologyPhysics or Chemistry)

* Note: Group F is only available to students who meet the following two conditions: (1) Be a US Citizenship and (2) Be a Junior (11th) or Senior (12th). Students who conduct research will receive a small stipend.

REFERENCES

Math and Science teacher recommendations are required. Another person in your school, church or community is acceptable if your school does not have a math or science teacher.

MATH TEACHER:
Last Name:
First Name:
E_mail:

SCIENCE TEACHER:
Last name:
First Name:
E-mail:

Application and teacher recommendation forms must be postmarked by Friday, April 12th, 2013; final decision will be made by April 30th, 2013.