Queensborough Community College STEP 2015 – 2016 Application
QCC- STEP APPLICATION 2015-2016
APPLICANT INFORMATION – STUDENT
Name:
NYSSID:
Student’s Phone #:
Home Phone #:
Student’s Email:
Current address:
City:
State:
ZIP Code:
New York State Resident: [ ] Yes [ ] No
Gender: [ ] Male
Grade In Fall 2015: [ ] 7th [ ] 8th
[ ] 9th [ ] 10th [ ] 11th [ ] 12th
[ ] Female
Ethnicity: [ ] African American (Includes all individuals of African descent) [ ] Hispanic/Latino
[ ] Native American/Alaskan Native
[ ] Pacific Islander [ ] Other:_____________________
Are you eligible for free or reduced price lunch through the USDA Income Eligibility Guidelines? [ ] Yes
[ ] No
Name of Middle/High School:
Math Course for the 2015 – 2016 Academic Year:
[ ] Algebra I [ ] Algebra II/Trig [ ] Geometry [ ] Pre-Cal [ ] Calculus
[ ] Other (please specify)_________________
Science Course for the 2015 – 2016 Academic Year:
[ ] Liv. Environment [ ] Physics [ ] Earth Sci. [ ] Chem.
[ ] Other (please specify)___________________
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name(s):
Address:
City:
State:
Zip Code:
Best Phone #:
Parent/Family Email:
EMERGENCY CONTACT
Name of a relative not residing with you:
Phone (H):
Phone (M):
Phone (W)
Which is the best contact
number on a Saturday?
Phone (M):
Phone (W):
Which is the best contact
number on a Saturday?
Relationship to STEP student:
Name of 2nd Contact:
Phone (H):
Relationship to STEP student:
STUDENT PHOTO RELEASE
I give permission/I do not give permission to the QCC STEP Program to use photographs (whether still or motion) for
publicity regarding this program.
____________________________________
Print full name of student
_________________________________
Student’s signature
For Official STEP Use
___________________________________
Parent/Guardian Signature
_________________
Date
[ ] New Student
[ ] Returning Student
Entry Date: