Peach State LSAMP Summer Bridge Research Institute

Please read carefully and complete all items. Incomplete applications will not be processed. Applications must be received by March 3, 2017. Review of application will begin immediately, however applications will be accepted until all available openings are filled. Application will be reviewed in the order that they are received. To be considered for participation in the summer bridge program send your application and current resume via email to [email protected].

Which 4-year college do you plan to attend? ______

What will your major be at the 4-year college? ______

Name: Male: Female:

Last First Middle

Place of Birth: Birth date:

Are you a citizen or a permanent resident? E-mail Address:

Overall College GPA: GPC ID#:900-

How Do You Identify Yourself? African American White American Hispanic/Spanish Surnamed Asian American Native American/American Indian Foreign National Other (Specify):

Permanent Mailing Address Present Mailing Address Number and Street: Number and Street: City: City: State: State: Zip: Zip: Telephone: Telephone:

Cell Phone #: Emergency contact #: Present Classification: Major:

Academic Information:

List the college science and mathematics and engineering courses that you have taken or in which you are currently enrolled. SUBJECT COURSE Grade COURSE Grade

In the space provided below describe in (no less than 350 words) your background and interest in the Summer Bridge Research Institute. Please include the following: Research interests (why are you interested in this area of research?), STEM career goals, lab skills or previous research experience (not required for this program), and what do you hope to learn or how do you hope to benefit from this program?

I certify that the above information is correct to the best of my knowledge. I understand that withholding information or giving false information may make me ineligible for the 2016 Transfer Summer Bridge Program. Stipend will be dispersed at the end of the program to those who have attended and participated in all of the events. Stipend will be deducted for planned activities that you do not attend.

NAME: DATE: