LSAMP Application2015Word - Louis Stokes Alliance for Minority

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LSAMP Application
Name: ____________________________________________________
Family Size (Living in Home):
1-3 
7-10 
4-6 
Other  (Please Specify _________ )
What is the highest degree received by your parents or legal guardian?
Father
Mother
Some High School


High School Diploma


Some College


2-Year College Degree


4-Year Baccalaureate Degree


Masters Degree (MS, MBA, etc.)


Doctorate or Other Terminal Degree


(JD, PhD, MD, DDS, etc.)
Legal Guardian (Specify _____ )







LSAMP LEADERSHIP ESSAY
Please type and attach an essay of 250 words describing your background and why you are passionate about
studying in the Science, Technology, Engineering, and Math related fields. Your essay should speak to your
commitment to full participation in the LSAMP initiative and how it can help you to achieve your goals.
ACADEMIC INFORMATION
Have you participated in any University of Connecticut pre-college programs through either the Storrs Campus or
the Health Center?
Yes
 (Specify:
)
No

Have you participated in any other pre-college programs for students interested in Science Technology Engineering
or Math (STEM):
University of Connecticut academic major:
LEADERSHIP INFORMATION
Please list any courses that you received college credit for while in high school:
Please list any honors or awards received including honor societies:
Please list extracurricular and community activities:
________
Career Interest:
Medicine
Dental Medicine
Biomedical Research
Nursing
Engineering
Computer Science
Biotechnology
Other







 (Specify_____________)
Highest degree that you plan to obtain:
BS/BA

MS

PhD

MD

DDS

Other
 (Specify_____________)
WORKING STYLE INFORMATION
Do you like to work in a group on a team project or alone? Also tell us why you choose this path:
When you have worked in a group tell us how you participated and what your role was on the group:
Please tell us how you have either sacrificed for the good of a group or how you build or support a group or
individual member:
PERMISSION
I give permission for _________________________________________________________ to participate in the
University of Connecticut Louis Stokes Alliance for Minority Participation (LSAMP) Leadership and Academic
Enhancement Program. I understand that participation includes attendance at all sessions of the required activities
outlined in the program descriptions, and that students may also have the opportunity to participate in job
shadowing, off-site research trips, and other relevant activities. This student has permission to attend these events
via approved transportation of the University of Connecticut. The Division of Diversity and Equity is given
permission to reproduce for publications any photos taken of this student at program activities.
I also consent to the disclosure of student information records maintained by the University of Connecticut on this
student. This information will be maintained in a confidential manner and will be used only for the purposes of
evaluation and program improvement. Use is consistent with the Federal Family Educational Rights and Privacy Act
of 1974, or other state or federal laws, regulations, or policies. I understand that this permission may be withdrawn
at any time.
I certify that the information submitted in this application is complete and true to the best of my knowledge.
_______________________________________
Date___________________________
Signature of Applicant
or Parent/Guardian (If applicant is under 18)
The deadline for application submission is August 12 2015.
Please Return To:
Marie McCain
Interim LSAMP Program Coordinator
Rowe/CUE 202
Phone: (860) 486-0653
Or e-mail it to [email protected]
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