North Star STEM Alliance
Fellows Application
2011-2012
Last name
First Name
Address
City
College or University
State
Department
Gender
Student ID
E-mail
School
Zip
Mentor
GPA
Telephone
Second e-mail
Enrollment status
Full-time
Part-time
Class
First-year
Sophomore
Ethnicity
Hispanic or Latino
Race
(check all that
apply)
Alaska Native
Asian
Black or African American
Native American
Disability Status
Hearing Impairment
Visual Impairment
None
Citizenship
U.S. citizen
Major or Interest
(choose one)
Middle Initial
Junior
Not Hispanic or Latino
Senior
Not reported
Native Hawaiian or Other Pacific
Islander
White
Not reported or Unknown
Mobility or Orthopedic Impairment
Other
Not reported
Permanent resident
Agricultural Science
Chemistry
Computer Science
Engineering
Environmental Science
Temporary resident
Geosciences
Life or Biological Sciences
Mathematics
Physics or Astronomy
Non-STEM
Name _______________________________
Program Interest
(choose all that
interest you)
Research – self directed, field or
laboratory.
Public speaking and presenting
Student leadership opportunities
Leading educational activities –
study groups, peer tutoring,
gatherings, etc.
Peer mentoring
Are you receiving financial support in the ’11-‘12 academic year?
Yes
No
Have you completed a FAFSA for ’11-‘12 academic year?
Yes
No
What aspects of your undergraduate education to date do you think are the biggest challenges
to your goal of earning a bachelor’s degree? Why?
How might the North Star STEM (science, technology, engineering and math) Alliance best
address your needs? What programs or services would best support your challenges?
How do you feel you can most effectively contribute to increasing the academic success and
engagement of underrepresented multicultural students in STEM disciplines at the
undergraduate level?
Authorization for Photography:
(initial) I hereby expressly grant the University of Minnesota, lead institution of the North Star
STEM Alliance, the right to make, use, and/or publish information, photographs, or any other reproduction
of my physical likeness for various communication efforts such as pamphlets, booklets, video tapes,
audiotapes, slide shows or internet sites. In addition, I expressly grant this right to be used for
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Name _______________________________
educational, marketing, and/or promotional purposes.
How This Information Will Be Used: The information you submit on this form will be used by
college/university officials and other Alliance administrators to evaluate your eligibility to become a
scholar, evaluate program effectiveness, and report data to the National Science Foundation (NSF) for
evaluation of overall program effectiveness. Please be assured that gender, race, ethnicity and disability
status information will not affect your eligibility to become a fellow, but the NSF requires the collection of
this information as a condition of program funding.
As a fellow, information about your participation in program events will also be provided to the NSF at the
end of the year, which is a prerequisite for you to be eligible for a stipend. If you wish to claim a stipend
for your participation in the program, you will be required to submit your SSN, which will be provided to
tax officials on order to process the payment. Please contact your site coordinator if you have questions
about the application process or information handling.
Signature required. Print, sign, initial above, and then fax or deliver.
Date
2011 - 2012
Please attach a copy of your current resume with this application to the site coordinator
at your college or university. Contact information is located at www.northstarstem.org
under partner organizations.
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