RIT LSAMP & MCNAIR SCHOLARS
Combined Application for Admission – Due October 5, 2015
Please send completed application to:
McNair Scholars and LSAMP Programs
Rochester Institute of Technology
Orange Hall, Room 1334
157 Lomb Memorial Drive
Rochester, NY 14623
Application for (circle all that apply):
LSAMP
McNair
Part I
Name:
Date:
_____________________________________________
______________________________
Email:
Date of Birth:
_____________________________________________
______________________________
University ID and Social Security No.:
College:
_____________________________________________
______________________________
Major:
Minor:
_____________________________________________
______________________________
Full-time Student (circle):
Yes
Year:
GPA in Major:
Cumulative GPA:
Expected Graduation Date:
___________________
_____________________
______________________________
No
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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:
______________________________________________________________________________
Parent/Guardian Home Phone Number:
______________________________________________________________________________
High School attended (name, city and state):
______________________________________________________________________________
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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
What is your Adjusted Gross Income? ______________________________________________
Number of family members in your family? __________________________________________
Are you a Pell Grant Recipient? Yes___ No ___
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 _____
CSTEP _____
Transfer Student______
Are you a first-generation college student? (ie. neither parent completed a four-year college
degree) Yes _______ No _______
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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. What are your career plans/goals, and how do they fit with the program you are
applying for? (Please attach an essay of at least 350 words)
2. For McNair Scholars Program applicants only:
Faculty and/or Staff Recommendation Letter:
Please include a sealed recommendation letter from a faculty and/or staff member that talks
about your academic potential, level of professionalism and maturity, readiness to work
independently as a scholar, your commitment to your academic goals, readiness to pursue a
graduate school education and conduct research, and how long they have known you and in what
capacity.
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Part IV
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
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
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_______/_______/________
Date