Collegiate Science & Technology Entry Program
Liberal Arts Hall, Room A-210
92 Lomb Memorial Drive
Rochester, NY 14623-5603
www.rit.edu/cstep
Office: (585) 475-4982 Fax: (585) 475-7120
- CSTEP
Application for Admission
Please send completed application to the above stated address:
Attn: Charlene Reagan
Program Assistant
Date: _____ / _____ / _____
Part I
Name:
_____________________________________________________________________________
Email:
Date of Birth:
_____________________________________________
______________________________
University ID#:
College:
_____________________________________________
______________________________
Major:
Minor:
_____________________________________________
______________________________
Full-time Student (circle):
Yes
Year:
GPA in Major:
Cumulative GPA:
Expected Graduation Date:
___________________
_____________________
______________________________
No
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2
3
4
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RIT Mailing Address:
______________________________________________________________________________
Home/Permanent Mailing Address:
______________________________________________________________________________
Cell Phone Number:
Home Phone Number:
_____________________________________________
______________________________
Name of Parent(s)/Legal Guardian(s):
______________________________________________________________________________
Parent/Guardian Address:
______________________________________________________________________________
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Parent/Guardian Home Phone Number:
______________________________________________________________________________
High School attended (name, city and state):
______________________________________________________________________________
Are you a New York State resident and have you lived in New York State for at least 12 months
(circle)?
Yes
No
Country of birth if other than USA: _________________________________________________
Citizenship Status (circle):
US Citizen
US Permanent Resident
Other (please specify)
Part II
Demographic Information
Gender: Male _____ Female _____
Ethnicity: Black, Non-Hispanic _____ Asian/Pacific Islander* _____
Native American or Alaskan Native _____ White, Non-Hispanic* ______
Hispanic/Latino _____ Other (specify)*___________
*Applicant Economic Eligibility to be verified by Financial Aid Office
Income Eligibility Questions (Answer only if your eligibility is based upon meeting
economic criteria.)
What is your Adjusted Gross Income? ______________________________________________
Number of family members in your family? __________________________________________
Are you a Pell Grant Recipient? Yes___ No ___
What is your EFC (Expected Family Contribution) Code? _______
**Please attach a copy of your FAFSA (Free Application for Federal Student Financial
Aid) form to this application.
Educational Background
Are you currently a member of another opportunity program? Please check all that apply.
HEOP _____ LSAMP _____
McNair _____
SSS Student_____
FSP
MCAS ______
Rochester City Scholar ______
_____ Honors _____
Transfer Student______
TRiO _____
Are you a first-generation college student? Yes _______ No _______
Were you a member of a STEP or CSTEP Program? Yes _______ No _______
Institution Name _____________________________________
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When _________________
Have you participated in a Summer Research Experience Program or internship in the past two
years? Yes/No
If yes, please provide the following information:
Name of Program:
Dates:
___________________________________________
______________________________
Location:
Advisor/Mentor:
___________________________________________
______________________________
Do you plan to apply to graduate school (circle)?
If yes, when do you anticipate attending?
Yes
No
______________________________________________________________________________
I want to receive a (check all that apply):
□ PhD.- Doctor of Philosophy □ MSW (Social Work)
□ Ed.D. Doctor of Education □ MPA (Public Administration)
□ MD Doctorate of Medicine □ MBA (Business Administration)
□ JD-Law Degree □ MAT (Teaching)
□ Other Doctorate □ Other Master’s Degree
Please specify_________________
Part III
1. Media/photo release waiver
I, ________________________________________, for consideration received, do hereby grant
to Rochester Institute of Technology (RIT), and its respective individual employees, directors,
officers, agents, representatives, successors and assigns, the absolute and irrevocable right and
unrestricted permission, for any purpose whatsoever and without further notice to me or any
other or further consent or authorization from me to use, reproduce, broadcast, telecast,
announce, publish, present and display my name, likeness, features, voice, manual language
expressions, identity, resemblance, quotations or photographs; whether alone or in combination,
and whether contained or depicted in any photographs, pictures, video, television, digital motion
and other electronic, media images or other recorded materials of me or in which I may be
included with others, either still or moving, live or delayed, or otherwise including any written
quotes of information that I readily shared with interviewers; and to copyright same and use
individually or in any and all media now and in the future for illustration, promotion, art,
editorial, advertising and trade or any other purpose and to use my name in conjunction with the
above. I agree that I am entitled to no compensation for any such use of my name, likeness,
features, voice, identity, resemblance, quotations or photographs other than what may have
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already been given to me. I assign to RIT all rights, title and interest that I may have in the above
referenced materials and waive all claim and title thereto and therefore. I do hereby release RIT,
its individual employees, directors, officers, agents, representatives, successors and assigns,
including the person who took or produced the above referenced materials, now and forever,
from any actions, suits, claims, covenants, damages, executions, demands and liabilities which I
or my heirs, representatives, successors and assigns ever had, now have or may have arising out
of the aforesaid authorization and consent, without limitation, including any claims for libel or
alleged misrepresentation of me by virtue of alterations or faulty mechanical reproduction.
_________________________________________
Signature
_______/_______/________
Date
Parent/Guardian Consent (required if under 18 years of age)
_________________________________________
Parent/guardian Signature
_______/_______/________
Date
2. Commitment statement
I, ___________________________________, agree to fully and respectfully participate in the
Collegiate Science and Technology Entry Program (CSTEP) at the Rochester Institute of
Technology. I fully understand that my academic performance will be monitored on a quarterly
basis and that I will be expected to attend all quarterly meetings, meet with my peer and faculty
mentor bi-quarterly, participate in at least one other CSTEP activity, and maintain good
academic standing. Failure to uphold these expectations may result in withdrawal from the
program.
__________________________________________
Signature
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_______/_______/________
Date