Minority Science and Engineering Improvement Program

Transcription

1 Funded by the U.S. Department of Education Minority Science and Engineering Improvement Program APPLICATION Texas A&M International University Minority Science and Engineering Improvement Program Office of Special Programs Student Center, Room University Boulevard Laredo, Texas Telephone: Ext Fax: DOCUMENTATION CHECK LIST A copy of your birth certificate or residency card A copy of your social security card Provide an official current academic transcript Waiver, Indemnification, and medical treatment authorization form Provide proof of income: a copy of your parents current tax records (1040 form), or if a tax return was not filed, proof of public assistance, a copy of a pay stub or check, and/or verification of free or reduced lunch Essay questions Math teacher recommendation Science teacher recommendation Other teacher recommendation Release of secondary and post-secondary education information Emergency Information SAT, ACT, THEA and/or TAKS scores

2 DATE: PERSONAL INFORMATION Name: SSN - - Last First Middle Mailing Address: Street or Box No. City State Zip Code Home Address: Street or Box No. City State Zip Code Phone: ( ) - ( ) - ( ) - Sex: Male Female Home Cell In Case of Emergency Address: Date of Birth: / / Age: U.S. Citizen: Yes No Legal Resident: Yes No Month Day Year (Please provide proof) Place of Birth:_ Shirt Size (Circle): S M L XL XXL Ethnicity: American Indian/Alaskan Native Asian White Black/African-American Hispanic/Latino No Response Native Hawaiian/Pacific Islander More than One Race Disability (Student): Yes No (Specify) ACADEMIC INFORMATION School Name: Classification: Class of Year of Graduation Are you currently enrolled in advanced placement or honors classes? Yes No Do you participate in any extra-curricular school activities: Yes No Activity (Band/Sports/Clubs) In what capacity? Does this involve Saturday or Summer activities? Yes No Yes No Yes No Yes No Have you participated in a science fair? Yes No If yes, what was the title of your project? Have you participated in U.I.L? Yes No Event(s) Academic Aspirations: High School Degree Only Vo-tech or trade school Two-year college degree only Four-year college degree only Advanced degree(s) Career Aspirations: What career or careers are you considering for yourself?

3 REFERENCE INFORMATION Please list references of three relatives not living in the student s household. Be sure to include address and telephone numbers since this information will be used for student tracking and emergency notification purposes. Name: Relationship to you: Address:_ Street or Box No. City State Zip Code Telephone Number: ( ) - Name: Relationship to you: Address:_ Street or Box No. City State Zip Code Telephone Number: ( ) - Name: Relationship to you: Address:_ Street or Box No. City State Zip Code Telephone Number: ( ) - FAMILY INFORMATION: Name of Parent(s)/Guardian(s) with whom you live: Parents Marital Status: (circle one) Married Single Separated Divorced Father remarried Mother remarried Father deceased Mother deceased Please list every person living in your home, including yourself. Also provide the information requested. Name Sex Age Relationship Do you have any brothers or sisters enrolled in the Minority Science and Engineering Improvement Program at TAMIU? Yes, Name: No

4 INCOME INFORMATION* TO BE COMPLETED BY APPLICANT S PARENT(S) OR GUARDIAN(S) The Minority Science and Engineering Improvement Program does not consider income information when determining eligibility.* The U.S. Department of Education has established educational and income guidelines which UBMS consider in determining eligibility. All information is strictly confidential and will be kept in the Office of Special Programs only. Please read carefully and complete ALL blanks. MSEIP at TAMIU does not discriminate because of a student s race, color, religion, sex, national origin, age, veteran status, disability or other characteristic that lawfully cannot be the basis for provision of acceptance. Father/Stepfather/Legal Guardian * Mother/Stepmother/Legal Guardian * Occupation: Place of Employment: Address (include City and State): Work Phone: U.S. Citizen Yes No Yes No Has either parent/guardian received a bachelor s degree? Yes No Family Household Income Information *: Father/Stepfather/Legal Guardian Mother/Stepmother/Legal Guardian Employment: $.00 $.00 Child Support: $.00 $.00 AFDC: $.00 $.00 Social Security: $.00 $.00 Disability: $.00 $.00 Unemployment Comp.: $.00 $.00 Other: $.00 $.00 Total Annual Household Income: Family Size: *OPTIONAL-Submit only if you would like to be considered for admittance into the TAMIU Upward Bound Math and Science Program. Include Copy of your current tax records (1040 form), or if a tax return was not filed, proof of public assistance, a copy of a pay stub or check, and /or verification of free lunch or reduced lunch is acceptable. RELEASE OF STUDENT INFORMATION (In compliance with the Family Education Rights and Privacy Act) I request that a transcript of my grades, and any other educational records required be released and made available upon request to the Minority Science and Engineering Improvement Program or Texas A&M International University for enrollment, tracking, and/or financial aid purposes. Accept Decline Student initials Parent initials PARENT CERTIFICATION My son/daughter has permission to apply for the Texas A&M International University Minority Science and Engineering Improvement Program. If selected he/she will be allowed to participate in all phases of the MSEIP. This includes twenty-six Saturday classes during the academic year and a six-week summer program. I also hereby certify that my total family income and all information as stated in the application for participation in the MSEIP Program at TAMIU, should I so choose to participate, is true and correct. Accept Decline Parent initials PUBLICATION RELEASE I give permission to the Texas A&M International University Minority Science and Engineering Improvement Program to display photos of myself and/or my son/daughter on the Minority Science and Engineering Improvement Program Website, newsletter and other publicity materials. Accept Decline Student initials Parent initials Student Name:Signature: Date: / / Please Print Parent Name:_Signature: Date: / / Please Print

5 EMERGENCY INFORMATION PRINT NAME DATE ADDRESS HOME PHONE _ CELLULAR Persons to notify in case of emergency: (Name) (Home Phone) (Work Phone) (Cell/Pager) (Name) (Home Phone) (Work Phone) (Cell/Pager) (Name of primary physician to be contacted) (Phone) (Name of alternate physician to be contacted) (Phone) (Please state any underlying medical condition or chronic illness that may be relevant during an emergency) (Please indicate the names of any medications to which the participant is allergic) (Please indicate any other allergic reactions participant may have. Ex: Peanuts, bees, ants, etc.) I give permission for the participant to: a. Receive emergency assistance as deemed necessary by TAMIU b. Receive over the counter medications available to TAMIU students (ex: Tylenol, Benadryl) c. Be transported to nearest medical facility if deemed necessary by TAMIU Participant Signature if 18 years of age or older) (Date) (Parent or Legal Guardian s Signature) (Date) SPECIAL NEEDS OR DISABILITY To help us better assist our students and ensure their academic success this summer, please complete the following: Does the student have any special needs or disability? (Please indicate and provide specifics.) ( ) No Disability ( ) Hearing impaired ( ) Speech impaired ( ) visually impaired /blind ( ) Mobility impaired ( ) Health impaired ( ) Learning disability ( ) other disability or special need: Specifics: What special and/ or instructional accommodations are you requesting M.S.E.I.P. to make for this student?

6 STUDENT ESSAYS Essay #1 You have been admitted into college and you have decided to live in a campus dormitory. The college has asked you to write a oneparagraph letter to your roommate describing yourself, your interests and your values. Write that letter in the space below. You may wish to write what is important to you in life and why. Essay #2 In the space below, state why you wish to participate in the Texas A&M International University Minority Science and Engineering Improvement Program. Essay #3 If your life goes as best as it can, what do you see yourself doing in 10 years? (Feel free to discuss career and personal goals.)

7 STUDENT PERSONAL DEVELOPMENT AND CAREER PROFILE: In order to prepare participants for success after high school, MSEIP will address issues of career exploration and personal development, as well as academic concerns. The following information will help identify the major issues facing student participants. On a scale of 0 to 5, with 0 indicating NOT a concern and 5 indicating CONSTANTLY a concern, please indicate how much of a concern each issue is for you. I would like to do the following: receive help in defining my goals. receive help in reaching my goals. learn about different careers. learn leadership skills. learn about making career decisions. learn how to get a job. learn how to make good decisions. know how high school courses relate to my career goals. get along better with my teacher(s). learn about financial aid for college. learn to handle negative peer pressure. develop confidence in myself. learn how to deal with my anger. learn how to handle stress. learn what my strengths are. learn better social skills. learn how to control my temper. learn how to make friends. talk with someone about personal issues. write better. learn to be a positive role model. be more motivated in school. Are you concurrently or dually enrolled? Yes No Last Semester Enrolled: Name of College or University: Intended Major of Study: Hours Earned: GPA: Which have you attempted: SAT, ACT, or THEA (circle all that apply) Date Last Tested: SAT Score: ACT Score: THEA: College Courses Taken; FOR OFFICE USE ONLY DATE REC: INIT: DATE ACC: INIT: Proof of Income: Tax Record: Public Asst.: Free/Reduced Documents: SS Card: Birth Cert: Prf. Of Res.: Transcript: GPA: Recommendations / / [FG]: [LI]: BOTH: Essays: Major: Last Enrollment Term: TAKS YR M S SS ELA Writing SAT / ACT / THEA / Release Form: Publication Release: Parental Permission to Participate Emergency Form MSEIP Waiver T-Shirt Size S M L XL XXL Accepted: Yes/No/Con Grade: Subjects: Math Science MSEIP Group: ID#:

8 TEXAS A&M INTERNATIONAL UNIVERSITY Supported by the U.S. Department of Education Minority Science and Engineering Improvement Program Release of Secondary and Post-Secondary Education Information I,, the undersigned parent/guardian, hereby authorize the TAMIU Minority Science and Engineering Improvement Program of Texas A&M International University or its authorized representatives or employees, bearing the release or copy thereof, to obtain any information pertaining to my son s or daughter s educational records including, but not limited to, enrollment status, academic standing, and transcripts with school seal. I hereby permit you to release such information. This release is executed with full knowledge and understanding that the information is for the use of the TAMIU Minority Science and Engineering Improvement Program to provide encouragement, support, and verification of educational progress. Your cooperation will be greatly appreciated. This authorization expires six years after entering a post-secondary institution. I agree to hold all harmless for any information that is released prior to the termination date as explained above in this release authorization. I give permission to the school listed below to release student records and information on my son or daughter to the Texas A&M International University s Minority Science and Engineering Improvement Program at this time and for the duration of his or her participation. I understand that these records will be requested throughout the time my son or daughter is enrolled in this high school. I understand this information will be used by Texas A&M International University s Minority Science and Engineering Improvement Program to establish eligibility for services, to develop individualized programming, and to document achievement of program objectives to the U. S. Department of Education. I also understand that all information will be kept confidential. Parent/Guardian Name (printed) : PARENT/GUARDIAN Signature: Date: Student Name (printed): STUDENT Signature: Date: Name of High School: Name of College/University: Release of secondary and post-secondary information.doc 10/11

9 TEXAS A&M INTERNATIONAL UNIVERSITY Supported by the U.S. Department of Education Minority Science and Engineering Improvement Program MATH TEACHER RECOMMENDATION FORM Name of Student Current Grade Level How long have you known the student? Please rate the student in the following areas: (Check Appropriate Spaces) Academic Potential Motivation Leadership Responsibility Over All Conduct Ability to follow instructions EXCEPTIONAL ABOVE BELOW NO BASIS FOR JUDGEMENT Are there any weaknesses or areas this student may need assistance with or improvement in? What kind of academic potential does this student possess? Please make a personal comment on how this student could benefit from the program. I strongly recommend Recommend Recommend with reservation Name Signature High School Date

10 TEXAS A&M INTERNATIONAL UNIVERSITY Supported by the U.S. Department of Education Minority Science and Engineering Improvement Program SCIENCE TEACHER RECOMMENDATION FORM Name of Student Current Grade Level How long have you known the student? Please rate the student in the following areas: (Check Appropriate Spaces) Academic Potential Motivation Leadership Responsibility Over All Conduct Ability to follow instructions EXCEPTIONAL ABOVE BELOW NO BASIS FOR JUDGEMENT Are there any weaknesses or areas this student may need assistance with or improvement in? What kind of academic potential does this student possess? Please make a personal comment on how this student could benefit from the program. I strongly recommend Recommend Recommend with reservation Name Signature High School Date

11 TEXAS A&M INTERNATIONAL UNIVERSITY Supported by the U.S. Department of Education Minority Science and Engineering Improvement Program RECOMMENDATION FORM: ANY OTHER TEACHER Name of Student Current Grade Level How long have you known the student? Please rate the student in the following areas: (Check Appropriate Spaces) Academic Potential Motivation Leadership Responsibility Over All Conduct Ability to follow instructions EXCEPTIONAL ABOVE BELOW NO BASIS FOR JUDGEMENT Are there any weaknesses or areas this student may need assistance with or improvement in? What kind of academic potential does this student possess? Please make a personal comment on how this student could benefit from the program. I strongly recommend Recommend Recommend with reservation Name Signature High School Date