95 HIGH STREET LIMESTONE, MAINE 207.325.3619
admissions@mssm.org www.mssm.org
Admission Application 2016
PERSONAL DATA
d
Legal Name:
Male
First {Given}
Middle
Last {Family}
Mailing Address:
Attach personal photo
{optional; however
strongly recommended)
Street Name and Number and/or PO Box
City
State
County
Postal Code
Contact Phone:
Student Email Address:
Date of Birth (mm/dd/yyyy):
Passport Number (Not required but strongly recommended):
Are you a US Citizen?
Yes
No
State of Maine Resident?
School presently attending:
Yes
No
School Phone:
School Address:
{Street}
Current Grade:
Female
Nickname
/
/
{City}
{Postal Code}
Year of High School Graduation:
Have you attended MSSM Summer Camp?
Yes
How did you first hear about MSSM?
No
Do you have any special dietary, physical or emotional needs?
Yes, please explain
Do you have any learning difficulties?
No
Yes, please explain
Do you currently have or have you ever had an IEP or 504 Plan?
No
Yes (Please explain in Family Supplement Section)
No
FAMILY DATA
Mr.
Mrs.
Ms.
Parent Name:
Mr.
Mrs.
Ms.
Parent's Occupation:
Parent's Occupation:
Address:
Address:
Contact Phone:
Contact Phone:
Alternate Phone:
Alternate Phone:
Email:
Email:
Parents Married
Parents Separated
Parents Divorced
Parent Name:
Father Deceased
Mother Deceased
Other
EXTRACURRICULAR
A. Please list or describe your extracurricular activities, including any special recognition received.
B. Also list those activities you would like to pursue at MSSM (regardless whether we currently offer it or not):
SHORT ANSWER QUESTIONS
This writing portion of the application recognizes the important role you will play as an individual member of our
community. In 150-200 words, please write in paragraph form about the following topics:
A. Identify a quality of a parent, guardian or an adult in your life who has significantly made an impact on you and whom
you would like to emulate.
B. Tell us how you envision the first few days as a student at the Maine School of Science and Mathematics.
ESSAY
In 350-500 words, please write approximately five (5) paragraphs in the proper writing format (introduction, body and
conclusion) on the following topic: {Please note we recommend submitting separately as all formatting is otherwise lost}
In his essay “Into the Electronic Millennium,” Sven Birkerts explores the relationships between technology, education, and
self. He argues that with the increased use of technology, language is eroding. “Simple linguistic prefab is now the norm,
while ambiguity, paradox, irony, subtlety, and wit are fast disappearing... The greater part of any articulate person's energy
will be deployed in dumbing-down her discourse.”
In a carefully reasoned essay that utilizes your reading and experience, support or oppose Birkerts' claim that the erosion of
language due to technology will lead to a more simplistic and less valuable use of language.
The items in this section are optional. This information will not be used in any discriminatory manner.
Language spoken at home:
First language, if other than English:
If you wish to be identified with a particular ethnic group, please check all that apply:
Black or African American
Hispanic, Latino
Caucasian
Native Hawaiian or Pacific Islander
Asian
Native American, Alaska Native
The information given herein is true and accurate. If the applicant is accepted for admission to the Maine School of Science and
Mathematics, we agree to adhere to rules and regulations now in existence and those that may be established in the future by the
school. We agree to permit information in this application and other records resulting from applying to and attending the school to be
made available on a confidential basis to the applicant’s home school, other educational institutions, and for MSSM-approved research
purposes. All application documents are retained by the MSSM. Unless otherwise directed, the MSSM reserves the right to release any
accepted applicant’s name and home town to the public.
_____________________________________ /_______________
Parent/Legal Guardian Signature
Date
________________________________ /_____________
Applicant Signature
Date