Regional Center for Math and Science      Regional Center for Math and Science

Student Application Form

Student Contact Information

Name
  Last First Middle
Address     
  Street Address
 
  City State Zip
Cell Phone #:

Birthday Information is used to
create your unique accountname:
Birth Month Birth Date

Do you qualify for Free & Reduced Lunch?
Yes    No    Unknown   

Student E-Mail*required*:

RETYPE Verify E-Mail:

 Gender:
Male    Female   

Select Your High School:

Grade During 2017-2018 School Year:

Race/Ethnicity (Please select all that apply)
Yes    No    Hispanic
Yes    No    American Indian/Alaskan Native
Yes    No    Asian
Yes    No    Black or African American
Yes    No    White
Yes    No    Native Hawaiian or Other Pacific Islander
Yes    No    Other
Other (please specify):   
Please check all of the areas of need that you believe apply to you:
(There are no “wrong” answers.)
Low scores on state tests
Low high school GPA
At the beginning of 10th grade, had not successfully completed pre-algebra or algebra course
Low educational aspirations
Lack of opportunity, support, and/or guidance to take challenging college prep courses
Lack of career goals and/or need for accurate information on careers
Limited proficiency in English
Lack of confidence, self- esteem, and/or social skills
Predominately low income community
Rural isolation
Interest in careers in math and science
Other
          Other Need (specify):
          
Math, Science, and Other STEM Grades
Letter Grade

Math

Algebra
Algebra 2
Geometry
Trigonometry
Letter Grade

Science

Biology
Chemistry
Letter Grade

Other STEM courses
(Science, Technology, Engineering, Math)

PRE-COLLEGE PROGRAM ALREADY ATTENDED (any Upward Bound, Talent Search,
or other academic program you may have attended)
Partner UB/ETS Programs:

Other Program Name:
Dates Attended (from - - - to)
Host Institution
City
State
Parent/Guardian 1 Information
Name
Last
First		  

Relationship to Student
Parent/Guardian E-Mail

Daytime Phone #
Cell Phone #
Has this parent/guardian earned a bachelor’s degree from
a 4-year college or university? Yes    No   
Parent/Guardian 2 Information
Change first and last to "Not Applicable" if you live in a single parent/guradian household.
Name
Last
First		  

Relationship to Student
Parent/Guardian E-Mail

Daytime Phone #
Cell Phone #
Has this parent/guardian earned a bachelor’s degree from
a 4-year college or university? Yes    No       Mark as "No" if you live in a single parent/guradian household.
The RCMS program prefers that all application materials and subsequent
paperwork be submitted electronically via the RCMS website or by e-mail.
If you prefer we will send the application and other paperwork via regular mail.
You will not be penalized for using paper copies of the forms versus electronic versions.

Please indicate your preference:

I prefer to have all paperwork mailed directly to me, using the address provided above.
I prefer to use electronic forms when available. I understand that the only form that cannot
be filled out electronically is the Eligibility Verification Form, which must be printed, signed,
and mailed.

Reference 1: We will send an email to this reference requesting
they complete the necessary form (you should follow up with them).

First Last
Email Address
Reference 2: We will send an email to this reference requesting
they complete the necessary form (you should follow up with them).

First Last
Email Address
Your Essay:
You may type this essay in Word or Google Drive, then copy and paste your
answers into this online form. Your essay should fully answer the two questions
below, use correct grammar and spelling, and be written professionally (use of
the first person—I, me, etc.—is acceptable). We use this essay to get a
glimpse of who you are as a person, so use your own voice and express yourself!

  1. In your own words, tell us why you want to attend the Regional Center for Math and Science.

  2. Describe your future educational plans and any career(s) you are interested in.
A 500 character minimum is Required to submit online!