ANSEP SUMMER BRIDGE APPLICATION FORM 2015

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1 APPLICATION FORM 2015 What is the ANSEP Summer Bridge? The ANSEP Summer Bridge focuses on developing students academically, socially and professionally for college and careers. Summer Bridge students enroll in a college math course and work a paid summer internship in the engineering or science field with one of the ANSEP Strategic Partners. All costs associated with the program are covered by ANSEP. Students who successfully complete their college math class and internship are eligible for scholarship funding to attend the University of Alaska, the fall immediately following Summer Bridge. What are the benefits of the Summer Bridge? Earn money for college Earn college credits Professional engineering & science experience Learn to navigate the University campus Lifelong friendships with fellow students Who should apply to the ANSEP Summer Bridge? Graduating high school seniors Interest in engineering or science careers Underserved/Underrepresented population Wants to earn money for college Planning to attend the University of Alaska (preferred) Where and when will the ANSEP Summer Bridge occur? The ANSEP Summer Bridge Component is 10-weeks long and held at the University of Alaska Anchorage (UAA) campus. Students will be housed on the UAA campus for the duration of the component. The 2015 ANSEP Summer Bridge will take place from May 24 th to July 31 st. Important ACT, SAT and Accuplacer Math Test Information Acceptance in the ANSEP Summer Bridge is determined by placement into one of the college-level math courses. Students who are taking college-level math classes for the first time must demonstrate their math level through college placement test scores. Math class placement is determined by the following chart: Math Course Placement Accuplacer (College-Level Math) Score ACT (MATH) Score SAT (MATH) Score MATH A105 < MATH A MATH A MATH A or higher 26 or higher 590 or higher For more information on the Math Accuplacer Test visit the UAA Advising and Testing Center website. (Web search for UAA Accuplacer ) **Note: A minimum placement into MATH A105 is required to register for the offered Math courses. 1

2 How do I apply to the ANSEP Summer Bridge Component? 1. Apply Online! OR 2. Submit all application documents together in one packet. Only complete applications will be considered. You will NOT receive notification of an incomplete application. Student application form (attached) Student records/transcripts Three letters of recommendation from teachers (at least one math teacher) or counselors 500-word essay explaining how you plan to contribute to the future of Alaska. Current ACT, SAT or Accuplacer Math Test Scores o If you ve previously taken a college math course, please indicate course(s) and grade(s) received Current Résumé (Tips: Mail or Deliver Application to: ANSEP Summer Bridge Attn: Michael Bourdukofsky 3211 Providence Drive, ANSEP 200D1 Anchorage, AK If you have any questions, you may contact Michael Bourdukofsky at or at You may also visit our website at Extended Application Deadline: Friday, February 20 th NOTE: Late applications will be considered ONLY if positions are still available. 2

3 APPLICATION FORM 2015 Type or print in blue or black ink. Please provide all requested information. of Birth (month/date/year): Gender: Female Male Regional/Village Corporation and/or Tribal Affiliation: Ethnicity: First-Generation College Student: Yes No Phone: Home Address: City: State: Zip code: Name of School student is currently attending: Type of School (Check one): K-12 Parochial Private Charter Home School Adult T-Shirt Size: Courses currently enrolled in for the academic year: Mathematics: Science: 3

4 Did you participate in any other ANSEP Pre-college Components? Yes No If yes, indicate which one and what year: Middle School Academy STEM Explorations Computer Assembly Acceleration Academy Possible Career Path(s) You are Interested in: Are you planning to attend the University of Alaska following graduation? Yes No If not, which University are you planning to attend? Have you ever taken a course through the University of Alaska? Yes No If yes, what course(s) did you take and when? If yes, what is your UA Student ID number? Note: If you forgot your UA Student ID you can look it up at Have you ever been convicted of a felony or misdemeanor? Yes No If yes, please explain (use separate sheet if necessary): 4

5 Please list school organizations, any science and/or mathematics activities (Science Fair, math club, after school programs, summer programs, etc.) you have participated in the past 3 years. Include awards received and offices held. You may attach a separate sheet, if needed. Please list any community activities and/or community groups that you have been a part of. Please list any other activity or achievement that you would like to share with the selection committee. A student-written essay must be included with this application. The essay should be typed or neatly hand written. The essay should be about 500 words. In your essay tell the selection committee How you plan to contribute to the future of Alaska. Include in your essay what you hope to gain from this experience, how you think it will help you in the future and why you think you should be selected to attend. Be sure to include your name at the top of your essay. Signature of Student 5

6 Instructions: Please complete the following information for at least one custodial parent or guardian, both, if available. Name of Parent or Guardian: Employer: Occupation: Daytime Phone No.: Home Phone No.: Cell Phone No.: Address: Signature of Parent or Guardian Name of Parent or Guardian: Employer: Occupation: Daytime Phone No.: Home Phone No.: Cell Phone No.: Address: Signature of Parent or Guardian Number of People in the Household: Family Yearly Income Level: Under $15,000 $15,001 to $30,000 $30,001 to $45,000 $45,001 to $60,000 $60,001 to $75,000 Over $75,000 6

7 REQUEST FOR RECORDS Please give this form to the registrar at your school. Your parent or guardian must sign this request so that the registrar can release the records. Dear Registrar: Please provide a copy of official records for this student (grades and standardized test scores), including this form in a sealed envelope, with your signature written across the flap, so these records will remain private. Please return the sealed envelope to the student or parent. The records must include a copy of the most recent grades/report card and test scores. This form must accompany the records. I hereby grant permission to the release of the information that this form is requested on my child. Name of Parent or Guardian (if a minor) Signature of Parent or Guardian (If a minor) Name of Student (Please Print) Student ID Number Signature of Student School Grade of Birth Registrar to fill this section: Does this child receive FREE or REDUCED lunch? Free Lunch Reduced Lunch Neither Name of Registrar (Please Print) Signature of Registrar 7

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