COLORADO ALLIANCE FOR MINORITY PARTICIPATION (CO-AMP) STUDENT APPLICATION/CO-OPERATIVE AGREEMENT FORM Academic Year: ___________ Date ___________________ I. Personal Information Name SS# School Address (on or off campus) School Phone E-mail address_________________________ Permanent Address City, State, Zip Permanent Phone Parent(s) Address (if different than above) ڤMale ڤFemale Age: Date of Birth: U.S. Citizen: ڤYes ڤNo Ethnicity: Permanent Resident ڤYes ڤNo ڤAfrican-American ڤNative American Tribal Affiliation ڤAlaskan Native ڤPacific Islander ڤHispanic/Chicano/Latino ڤOther, please specify______________________________ II. Academic Information Do you have an Associate’s Degree? ڤYes ڤNo From Where? Major Semesters at current campus Minor Year in School: ____FR (0-29 crs) Cumulative GPA _________ ____SO (30-59 crs) ____JR (60-89 crs) ____SR (90+ crs) GPA in Major Field _________ Did you have an internship this past summer and with whom? ڤYes ڤNo _______________________________________________________________________________________ Did CO-AMP assist you in receiving this internship? ڤYes ڤNo III. What Services would be most beneficial to you? Check the areas in which you are interested: (These are services that CO-AMP furnishes or to which CO-AMP can refer you) Being Tutored Tutoring (see below)** Faculty Mentoring Scholarship Info Financial Aid Info Academic Advising Study Skills Workshops Undergraduate Research Summer Opportunities Elsewhere Student Organizations Career Counseling Major/Career Exploration Graduate School Info/Prep Internship Info Cultural Events Industry Tours Travel support to minority conferences ** If you are tutoring, please indicate the specific class subject names here___________________________ IV. Co-operative Agreement CO-AMP is here for your academic success. Students please keep in mind that CO-AMP is here to help you achieve your academic, social and professional potential. Therefore, the CO-AMP staff requires this aforementioned information to assist you in achieving your goals. By signing immediately below, you authorize CO-AMP staff to obtain from or release to Admissions, Registrar, Financial Aid, or other offices on or off campus, any records or data pertinent to participation in the program, specifically, by facilitating academic advising and academic tracking by accessing your grades. Signature Date The following opportunity is optional, but may be to your academic advantage to sign. By providing an additional signature below, and remember this is optional, you authorize the release of your name, address, email and phone number to CO-AMP and its participating four-year institutions (if you are presently attending a community or junior college) and graduate schools to contact you concerning educational opportunities and fellowships at their respective institutions. Signature Date The LOUIS STOKES COLORADO ALLIANCE FOR MINORITY PARTICIPATION (LS CO-AMP) is an innovative consortium of thirteen community colleges and four-year institutions, and four Native American tribes in Colorado and the Four Corners region. The Alliance's mission is to double the number of historically and currently under-represented American Indian, African American, and Hispanic students earning bachelor's degrees in Science, Mathematics, Engineering, and Technology.