Prep Application Form

NC-MSEN Pre-College Program, Suite 222, College of Education, 9201 University City Blvd., Charlotte, NC 28223 Ph. 704 687-8728 Fax: 704 687-1497 [email protected]

2014 RESEARCH EXPERIENCE FOR 11TH AND 12TH GRADE STUDENT INTERNSHIP APPLICATION FORM (Please type or write legibly.) Student Profile ______Male ____ Female ____ Name Last First M.I. ______-____-______Date of Birth Social Security Number Current GPA

______Home/Mailing Address

______City State Zip Telephone (include area code) ______Parent/Guardian Other Home Phone/Business ______High School Address ______City State Zip Telephone (include area code) Grade level for the school year 2014-2015 (please circle): 11th grade 12th grade Are you currently a UNC Charlotte NC- MSEN Pre-College Student (please circle): Yes No Please circle the science classes that you have completed: Biology Chemistry Physics Other Science Courses: Please circle the math classes that you have completed: Common Core HS Math 1 Algebra II Common Core Math 2 Pre-Calculus Statistics Calculus

Other Math Courses: ______Please list any technology classes that you have completed:  The information you provide when answering the following question will maximize opportunities for student interaction with peers from different racial/ethnic and geographic backgrounds.  Which of these categories best describes your ethnic/racial status? Please circle one. African American Alaska Native American Indian Asian American Caucasian non-Hispanic Filipino American Hispanic American Pacific Islander Other (specify) ______Eligibility (Circle yes or no for each statement)  I am a resident of North Carolina, and a citizen of the United States. Yes No  I am willing to participate in a formal interview if chosen as a finalist. Yes No  I am committed to full participation throughout the seven weeks of the program, the workshop, and follow-up classroom activities. Yes No Student Essay Prepare a one page, typed, 12” font, Times New Roman essay (see essay page). Recommendations Obtain recommendations from at least two mathematics and/or science teachers (you can get the form at the Teacher Recommendation Form – you must use this form). Resume Please enclose your resume with this application. ______Signature of Applicant Date

PRE-ASSESSMENT

In order to meet your needs and those of the preceptors (mentors) we would like to have the following information from you. Please return the information by date (posted marked) to the above address, attention Mrs. Shagufta Raja.

Please indicate your computer skills and computer access below.

Know Know Quite a I am an Skill I am a Beginner Something Bit About It Expert About It Using a computer Using Microsoft (MS) Windows Using MS Power Point Using MS Excel Using MS Word Using MS Outlook Using a browser and the Web Computer Programing

Question Do you have access to computer at home? Yes: No: What kind of home computer? PC Apple Other Do you have access to the Internet at home? Yes: No:

Other computer skills: ______

______

2 Student Course/Profile

Please have your school provide us with a copy of your high school transcript . In addition, please provide the following information. These grades must match those on your transcript. Please note Advanced Placement courses using (AP), IB courses or Honors.

Letter Grade Received Exact Title of Course Grade level when taken

CC HS Math I ______Algebra II ______CC Math II ______Other Math ______Biology ______Biotechnology ______Chemistry ______Physics ______Engineering ______Technology ______Other Science ______

Overall School Grade Point Average______(weighted) and ______(unweighted)

Standardized Test Scores, if known or taken. PSAT (total) =_____ SAT (total) = ____ ACT (total) = _____

Are you now, or were you recently, involved in any extracurricular or volunteer activities related to mathematics, science, or technology? If so, please describe.

Have you participated in summer internship programs in the past? If so please describe.

Student Profile  I will be at least 16 years of age by the start of the Program. Yes No  Date of birth (mm/dd/yy) ______.  I am currently enrolled in: Please specify grade level Rising Junior Rising Senior  I have completed at least one semester of algebra, at least one semester of geometry, and at least one year of biology, chemistry, or physics with a grade of B or better in each course. Yes No

3 UNC Charlotte CSTEM NC-MSEN Pre-College Program Student Essay

Applicant’s Name High School City

Submit a 500 word, typed, 12 inch font – Times New Roman, essay addressing the following:

 Career and research interests in STEM disciplines.

 Personal expectations from the program

 How participation in the program will add to your personal academic development in STEM.

 Availability to participate in STEM related conferences and competitions.

4 Mail completed application:

Shagufta Raja, MS NC-MSEN Pre-College Program The Center of STEM Education College of Education, Suite 222 UNC Charlotte 9201 University City Blvd Charlotte, NC 28223

5 UNC Charlotte CSTEM NC-MSEN Pre-College Program