LaGuardia Community College
Collegiate Science and Technology Entry Program (CSTEP)
Funded by New York State Education Department
Date:______________________
Student Name: ________________________________________________S.S.#___________________________
Address: ____________________City___________________________State_________Zip Code _____________
Email:____________________________________________Phone Number: __(_____)_____________________
Major: __________________________________Career Objective:______________________________________
 Yes
 Yes
 Yes
A. Full-time Student?
B. NYS Resident?
C. Citizen
 No
 No
 No
D.
New York State Resident?  Yes
Registration No.: ____________________________
Country of birth, if other than USA:_________________
Gender Male  Female
Ethnicity:
 No
Date of Birth: ___________________________
Completed basic skills  Yes  No
1.  African-American/Black
3.  Native American Indian/Alaskan Native
5.  Asian/Pacific Islander
My Current GPA:_____________
2.  Hispanic/Latino
4.  White
6.  Other
If you checked 4, 5 or 6:
Are you economically disadvantage according to the criteria on the REVERSE side?  Yes  No
(Please circle on reverse side)
I would like to participate in the following CSTEP Activities:
 Academic Workshops
 Scholarship Information
 Career Development Seminar
 College Visit
 Group Meetings
 Lecture by Visiting Professional
 Licensure Preparation
 Poster Presentation
 Professional Conferences
 Project Newsletter
 Research
 Targeted Advisement
My preferred times for activities:
 Sun.  Mon.  Tues.  Wed.  Thurs.  Fri.  Sat.
 Morning
 Afternoon
 Textbook loan
 Trips
 Tutoring (Specify Subject)
__________________________
 Website Development Activities
 Workshops (e.g. test preparation)
 Evening
 Intersession
I, ________________________________ agree to fully participate in the Collegiate Science and
Technology Entry Program (CSTEP) at LaGuardia Community College.
_____________________________________________
Signature
________________________
Date
PLEASE return this form to CSTEP mailbox in E300 or to CSTEP staff in E342. Thank You.