STEM Institute July 20 – 8 August, 2008
STUDENT APPLICATION
Please print legibly in dark ink, or type.
STUDENT INFORMATION
____ Option A – College credit only
Social Security number_____________________________ ____ Option B – High school and college credit
____New Student ____ Returning STEM Student (Participated in 2007 Institute)
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Legal Last name First Middle Gender (check one) ___Male ___Female
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Street Address City State Zip
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E-mail address Birthdate (Month/Day/Year)
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Name of custodial parent or guardian/Last First Middle Emergency phone number/Name
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Street address City State Zip
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Home telephone number Cell number
EOC information is strictly voluntary and used only in reports to the federal government. Check one:
___African American/Black ___ American Indian ___Asian ___Caucasian ___Hispanic ___International
___Other ______________
RESIDENCY INFORMATION
Citizenship __U.S Citizen ___Permanent residency (Provide copy of 1-551) County of residency___________________ State of residency _____________
Dates student has lived in Ohio From________ To_________ Dates parent/guardian (circle one) has lived in Ohio From _______ To ________
Are you on active military duty in Ohio or a dependent of such a person? ___Yes ___No Are you employed full-time in Ohio? ___Yes ___No
Are you claimed as a dependent by a parent or guardian? ___Yes ___No
ACADEMIC INFORMATION
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High school currently attending City State ACT/SAT Expected high
High school code school graduation date
TO BE COMPLETED BY THE SCHOOL COUNSELOR
This student’s status at time of enrollment will be:
Junior __________ Rank __________ Class Size __________ ACT/SAT Scores __________
Senior __________ Number of College preparatory courses completed__________ Number in progress __________
This student ___ has ____ has not passed all parts of the Ohio Graduation Test required for high school graduation or has qualifying exemption.
Official copy of ___ Transcript and ___ Standardized Test scores provided.
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Signature of Guidance Counselor Date Telephone Number
RECOMMENDATION FORM. This section must be completed by the student’s math or science instructor and signed by the student’s counselor.
Please support the applicant with your recommendation. Recommendations will be a factor in the decision to admit applicant.
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1. _______________________________ ________ 2. _______________________________ ________
Math/Science Instructor’s Signature Date Counselor’s Signature Date
TO BE COMPLETED BY THE CUSTODIAL PARENT OR GUARDIAN
By my signature below, I endorse and support my son’s / daughter’s participation in the STEM Institute at Wright State University.
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Custodial Parent’s/Guardian’s signature Date
RETURN APPLICATION MATERIALS WITH $75 APPLICATION FEE TO:
Mailing address: Walk-in address: Student Application Checklist
Office of Pre-College Programs 3821 Colonel Glenn Hwy. Completed Student Application
Wright State University 100 Word Autobiographical Essay
3640 Colonel Glenn Hwy. Recommendation Form
Phone: (937) 775–3135 Most Recent Grade Report and
Fax: (937) 775–4883 Standardized Test Scores
Web site: www.wright.edu/academics/precollege $75 Nonrefundable Application Fee
PAYMENT INFORMATION $75.00 Application Fee Enclosed __________ Balance Due on June 30, 2008 $552.00
Personal check number______________________ Amount $_______________________ Date________________ Make checks payable to Wright State University
___MasterCard ___VISA ___Discovery Amount $____________
Card number ____________________________________ Expiration date _____________________
Name of Cardholder________________________________________________________________________________
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