PRAIRIE VIEW A&M UNIVERSITY DEPARTMENT OF ELECTRICAL AND COMPUTER ENGINEERING
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PRAIRIE VIEW A&M UNIVERSITY DEPARTMENT OF ELECTRICAL AND COMPUTER ENGINEERING 2011 Summer Engineering Education Camp for Middle School Application The Application deadline is May 25, 2011. Date: ____________________ Student’s Name: ____________________ Date of Birth: ____/___/____ mm / dd / yyyy SSN# ______-____-______ Tel #:______-____-______ (confidential, used only for research on program effectiveness) Physical address:___________________________________________________ _________________________________________________________________________ Middle School Name: Circle appropriate answer. Gender: Male Female Race/Ethnicity: African-American Hispanic Asian/Pacific Islander American Indian/Alaskan Native White Other (please specify): _______________________ Primary Language Spoken at Home: English (specify:___________) Spanish Other How did you hear about the Engineering Recruitment Summer Program? Counselor Teacher Flyer/other advertisement Letter from your school/district must be attached in this application form Other (please specify:) _____________________________ Mother/ Female Guardian Father/ Male Guardian No High School No High School Educational Attainment of Parents/Guardians (circle the highest level completed) Some High High School Some Bachelors School Graduate College Degree or higher Some High High School Some Bachelors School Graduate College Degree or higher SEEC (ERP Summer Program 2011) Don’t know/ Not Applicable Don’t know/ Not Applicable Did you or any member of your family qualify for the free or reduced lunch program during the 2010-11 school years? (circle only one answer) Yes No Not applicable/Don’t want to answer Mail your application to: Dr. Warsame H. Ali Program Director Department of Electrical and Computer Engineering PO Box 519, Mail Stop 2520 Prairie View, Texas 77446-0519 Or FAX at : (936) 261-9930 SEEC (ERP Summer Program 2011) List the following Extracurricular activities in high school (example - sports, choir, school newspaper): Awards and/or Honors (example – placing in academic competition, honor roll, etc.): Community Service Activities (example – volunteering with homeless, tutoring younger students, etc.): Check the best answer. I plan to go to college when I finish high school. My parents/guardians are encouraging me to go to college. My friends plan on going to college. I enjoy school. My teacher(s)/counselor(s) care if I go to college. I am interested in a specific college(s). Please specify: ____________________ ____________________ Strongly Agree Agree I have a specific career goal(s). I am interested in a career in engineering. Disagree Not Sure/ Neutral Strongly Disagree Which High School Plan do you expect to graduate under? (circle only one answer) Minimum Recommended Distinguished Don’t Know Other (specify: __________) Grade level spring 2009: 6th 7th 8th 9th 12th 10th 11th other (specify: __________) __________________________ ____________________ _______________________ Name of School (spring 2011) City ISD SEEC (ERP Summer Program 2011) Student Consent Form 2011 Summer Engineering Education Camp for Middle School Application THECB Engineering Recruitment Summer Program 2011 Date: ______________ Student’s Name: ________________________________ SSN# ______-____-______ High School ID Number: ______________ (confidential, used only for research on program effectiveness) Parent/Guardian’s Name _________________________________________________________ [INSERT NAME of INSTITUTION] and the Texas Higher Education Coordinating Board are using student data to evaluate the effectiveness of this program. All data is confidential. It will be reported only in the aggregate and for the express purpose of measuring and reporting on the effectiveness of this program. I/we understand that any such information will be used by [institution] and the Texas Higher Education Coordinating Board only for these purposes, that [institution] and the Texas Higher Education Coordinating Board will not disclose any such information that personally identifies a student to any other party, and that any report generated on the basis of this information will not personally identify any student. __________________________________ Student Signature SEEC (ERP Summer Program 2011) _____________________________ Parent or Legal Guardian (Required, if student is 18 years of age or younger) Formulario de consentimiento del estudiante 2011 Summer Engineering Education Camp for Middle School Application Programa “Engineering Recruitment Summer Program” Fecha: ______________ Nombre del estudiante: __________________________ Número de seguro social ______-____-______ Número de identificación de la escuela secundaria (si está disponible): ______________ (Confidencial, usado sólo para la investigación de la efectividad del programa) Nombre del padre, madre o tutor: _________________________________________________ [INSERTE EL NOMBRE DE LA INSTITUCIÓN] y la Junta Coordinadora para la Educación Superior en Texas están usando los datos de los estudiantes para evaluar la efectividad de este programa. Todos los datos son confidenciales. Sólo serán informados de manera agregada y con la finalidad expresa de medir e informar la efectividad de este programa. Yo/Nosotros comprendemos que dicha información será usada por [institución] y la Junta Coordinadora para la Educación Superior en Texas solamente para estos fines, que [institución] y la Junta Coordinadora para la Educación Superior en Texas no darán a conocer a ninguna otra parte, ninguna información que identifique personalmente a un estudiante, y que cualquier informe generado en base a esta información no identificará personalmente a ningún estudiante. __________________________________ Firma del estudiante SEEC (ERP Summer Program 2011) _____________________________ Padre, madre o tutor (Necesario si el estudiante tiene 18 años o menos)
