College Credit Plus
Science Experience Internship
Last Name____________________________ First Name ______________________________
Cell Phone (______) ____________________ Home Phone (______) _____________________
Email Address __________________________________
High School Name ______________________________
Current HS Grade Level: Freshman _____Sophomore ______Junior ______Senior _______
Expected High School Graduation Date: ________________
Intended College Major ________________________________________Undecided ________
Have you participated in any extracurricular programs involving math-science-technology activities, such as a science camp or robotics team? If so, please describe below.
Students applying for a Science Experience Internship should indicate a desired area of study to assist with placement. Placement is determined by a student’s indicated research interest and availability of participating faculty advisors.
Please indicate area(s) of research interest for
Science Internship placement. If you have more than one area of interest, please indicate preference using numbers 1-6.
______ Biology
______ Chemistry
______ Computer Science
______ Geology
______ Physics
______ Psychology
Personal Information (for reporting purposes only):
Gender: ________________
Ethnicity:
__Hispanic or Latino
__Not Hispanic or Latino
Race (may choose more than one)
__American Indian or Alaska Native
__Asian
__Black or African American
__Native Hawaiian or Other Pacific Islander
__White
__Other________________