UPWARD BOUND MATH/SCIENCE REGIONAL INSTITUTE
APPLICATION
(Part 1 of 2)
First name:
Last name:
Age:
E-mail Address:
Full Name:
Gender:
Male
Female
Address:
City:
State:
Zip Code:
Telephone Number:
Date of Birth:
Social Security Number:
U.S. Citizen
YES
NO
Ethnic Origin:
American Indian/Alaskan Native
Asian/ Pacific Islander
Hispanic
Black (Non-Hispanic)
White (Non-Hispanic)
Other
Current Grade Level:
Current School:
G.P.A:
Career Interests:
Educational Plans:
4-Year College
2-Year College
Vocational/Tech
Military
Other
Do you have a disability (physical,emotional, learning)?
NO
YES
If So, describe:
Math Classes Completed:
Math Courses Planned for Next Year:
Science Classes Completed:
Science Courses Planned for Next Year:
Is Either Parent/Guardian a graduate of a 4-year college or university?
Yes
No
If Yes, name of school:
Number of persons living in the household:
Family Income:
With Whom Do You Live With:
What clubs, hobbies, or extra-curricular activities do you participate in?
What are your favorite and least favorite courses at school and why?
In your opinion, what is the most significant mathematical or scientific development that affects our everyday lives? Defend your perspective
Why do you want to participate in the Math/Science institute? What do you expect to require by your participation and what will you contribute?
Have you made any commitments that would prevent uninterrupted, complete participation for the time period June 17, 2005 through July 23, 2005?
Do you need transportation to Morehouse College?
Yes
No