UT Arlington Pre-Freshman Engineering Program (PREP) Year 1 Application 2014

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1 UT Arlington Pre-Freshman Engineering Program (PREP) Year 1 Application 2014 Arlington TexPREP Dates: Tuesday, June 10 th Friday, July 18 th, Weekdays 8:30 AM 3:30 PM. Hosted by UTA Department of Mathematics on 3 rd Floor of Pickard Hall, 411 S. Nedderman Dr. Directions: All parts (1-5) of this application must be completed or it will be considered incomplete, and will not be processed. Late applications will be considered only if positions are available. If positions are not available, the applicant will be put on a waiting list. Please type or print clearly. Part 1 to be completed by applicant: Social Security number: Gender: [ ] Female [ ] Male Address: Number and Street (Apt. Number) City, State, Zip code Phone number: Date of birth: Age: address: Ethnicity (This is for information only and does not affect your application.): [ ] American Indian [ ] Anglo [ ] African American [ ] Hispanic [ ] Asian/Pacific Islander Citizenship: [ ] U.S. Citizen [ ] other (please indicate): Current grade level: [ ] 6 [ ] School: District: School: District: Part 2 to be completed by parent or guardian: Father s or Guardian s name: Work phone: ext Highest grade or degree: Mother s or Guardian s name: Work phone: ext Highest grade or degree: Emergency contact (other than parents): Relationship: Phone: Parent/Guardian consent: As the parent/guardian of the above-mentioned student, I certify that my child has my permission to participate in the PREP program. He or she is committing to attend PREP Monday through Friday for six weeks. It is my understanding that my child will be subject to PREP regulations. I give my permission for PREP to share basic information regarding my child. (This is necessary to use computing facilities at UTA.) Parent/Guardian signature: Applicant s signature: Date: Date:

2 Part 3 - to be completed by applicant: Grades: Attach a copy of your latest grade report. Nomination Forms: Please have two teachers fill out the nomination forms and mail them to us separately. One of them must be a math teacher. Essays: Please write a word essay on why you want to attend PREP. Please check below the subjects that you have studied thus far (ask your math teacher, if necessary): [ ] Pre-Algebra [ ] Geometry [ ] Algebra I [ ] IB How did you hear about TexPREP? [ ] Teacher [ ] Principal [ ] Counselor [ ] Poster or flyer [ ] From a former participant [ ] School presentation [ ] I am a former participant [ ] Other: Career interests T-Shirt size (adult sizes): S M L XL XXL

3 Nomination Form Directions: Please type or print clearly. Without this nomination form, a student's application will be considered incomplete. Especially important is your evaluation of the student's desire to work hard and to learn during this six-week program. Please respond as fully as possible; do not return to student.* Your assistance is greatly appreciated. Part 4A - to be completed by applicant: SS#: School: Current grade level: Part 4B to be completed by mathematics teacher: i. Place an "X" in the appropriate column for each characteristic listed: Characteristic Excellent Good Fair Poor Academic performance Conduct in class Participation in class Respect for others and their property Ability to follow instructions Completes assigned work on time Analytical thinking Maturity Punctuality Eagerness to learn new things Motivation for summer program ii. iii. Indicate current math course(s) you are teaching applicant: Please provide comments on motivation, ambition, behavior, personality, etc., that you feel are pertinent to the student's performance in PREP. If the student fails to satisfy some academic requirements, please explain in detail. (Please use the back of this form or attach an additional sheet if necessary.) Teacher s Printed Name/Title Teacher's Signature Telephone Number Date *Mail completed Nomination form to: 411 S. Nedderman Dr., Box 19408

4 Nomination Form Directions: Please type or print clearly. Without this nomination form, a student's application will be considered incomplete. Especially important is your evaluation of the student's desire to work hard and to learn during this six-week program. Please respond as fully as possible; do not return to student.* Your assistance is greatly appreciated. Part 5A - to be completed by applicant: SS#: School: Current grade level: Part 5B to be completed by English teacher, science teacher, or counselor: i. Place an "X" in the appropriate column for each characteristic listed: Characteristic Excellent Good Fair Poor Academic performance Conduct in class Participation in class Respect for others and their property Ability to follow instructions Completes assigned work on time Analytical thinking Maturity Punctuality Eagerness to learn new things Motivation for summer program ii. iii. Indicate current course(s) you are teaching applicant: Please provide comments on motivation, ambition, behavior, personality, etc., that you feel are pertinent to the student's performance in PREP. If the student fails to satisfy some academic requirements, please explain in detail. (Attach additional sheet if necessary.) Teacher s/counselor s Printed Name/Title Teacher's/Counselor's Signature Telephone Number Date *Mail completed Nomination form to: 411 S. Nedderman Dr., Box 19408

5 Checklist Applicant or counselor - This checklist is provided for your convenience: [ ] Did you read the entire application? [ ] Did you attach a copy of your latest grade report for the school year? [ ] Did you answer all the questions on the student application form? [ ] Did you attach your essay? [ ] Did your parents sign the application? [ ] Did you have two teachers submit a completed nomination form directly to us? [ ] Did you make a copy of your application packet for your files? A complete packet includes: Student application form (Parts 1, 2, and 3 There are two pages.) A copy of a recent grade report for this year Essay 2 nomination forms (Parts 4 and 5) Your packet should be mailed to UTA to the address provided below, on or before May 9, Mailing Address: 411 S. Nedderman Dr. / Box Contact Information: Phone Number: or Web Site:

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