STEM RISING FRESHMAN SUMMER INSTITUTE 2011
Application Form – Deadline April 15, 2011
Please type or print all information requested below. Your legal guardian’s signature is required.
Name: _________________________________________________________________________ SS#: __________________
(Last)
(First)
(Middle)
Phone: ________________________________________ Gender: Male _____ Female______
(home#)
(cell#)
Age: ________________
Email and Mailing Address: ______________________________________________________________________________
(email address)
(Number and Street/Apt)
_____________________________________________________________________________________________________
(City)
(State)
(Zip code)
Do you intend to enroll at Tennessee State University for Fall 2011? _____ Yes
_____ No
Intended STEM Major at TSU (refer to attached list of STEM majors offered at TSU and check all that apply):
Agricultural Science/Pre-Vet _____ Biology _____
Mathematics _____ Physics _____
Chemistry _____
Computer Science _____
Engineering _____
High School: ____________________________________ _____________________________________________________
(Name)
(Phone: include area code)
(Date of Graduation)
High School Address:
Test Scores:
(Enter all
that apply)
ACT
English________
Math_______
SAT
Verbal_________
Math ______
Science________ Composite___________
Please indicate the grades you received in the courses listed below:
Algebra I_________
Algebra II________
Geometry________
Trigonometry_________
Pre calculus__________
Calculus_____________
AP Calculus________
Physics____________
English (Sr.) _______
Chemistry_________
Computer_________
Other STEM Courses_____________________________________________________________________________
Awards and Activities. Please list all awards and/or activities in the order of their importance to you and check the year you received
the award(s).
Award/Activity
___________________________
Fr
__
So
__
Jr
__
Sr
__
Position Held
_________________________
___________________________
__
__
__
__
_________________________
Others: ____________________________________________________________________________________________
Parent (legal guardian) Name: __________________________________________________________________________
(Last)
(First)
(Middle)
Parent (legal guardian) Home, Work & Cell Phone Numbers: _______________________________________________________
I certify that all information provided on this application is complete, accurate, and honestly presented.
________________________________________________
________________________________________
Signature of Applicant
Parent/Guardian Signature
The HBCU-UP Project at TSU is funded by a grant from the National Science Foundation (HRD-0715004)