UPWARD BOUND MATH/SCIENCE STATE CENTER

APPLICATION
(Part 1 of 2)

PLEASE ANSWER ALL QUESTIONS.  FAILURE TO DO SO WILL RESULT IN NON-CONSIDERATION OF THE APPLICATION.

ALL APPLICATION ARE DUE BY THE THE LAST BUSINESS DAY IN MARCH.



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:


Why do you want to participate in the Morehouse College Upward Bound Math/Science State Center?  What do you expect to learn or gain from your participation and what will you contribute?


What are your plans following graduation from high school?  What careers are you interested in pursuing??


In your opinion, what is the most significant mathematical or scientific development that affects our everyday lives? (Please defend your perspective)


What are your favorite and least favorite courses at school and why?


What are your strengths and what weaknesses would you like assistance with?

Have you made any commitments that would prevent uninterrupted, complete participation for the time period June 3, 2005 through July 15, 2005?


Do you need transportation to the Upward Bound Math/Science State Center? Yes No