Summer Math Academy PDF Summer Math Academy program because…….

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Summer Math Academy program because……. On a separate sheet of paper complete the following statement in 100 words or less:.

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Summer Math Academy

July 10 July 22, 2016 Think, Work, Serve

Date of Birth:

Home/Local Phone

Student Cell Phone

Student Name (Last, First, Middle Initial)

Local Mailing Address

City State Zip

Parent/Guardian Name(s))

Name of High School Grade Point Average GPA

What grade will you be in

next school year (Fall 2016)?

Favorite Course Subject(s)

For Office Use Only

DATE TIME

Campus/Community Organization Office Held Campus/Community Organization Office Held Campus/Community Organization Office Held Please list all campus/community organizations and any offices held

Notes:

I should be chosen to participate in the TSU Regents

Summer Math Academy program

On a separate sheet of paper, complete the following statement in 100 words or less: RETURN THIS APPLICATION BY THURSDAY, MAY 26, 2016 to:

Dr. John Robinson

Regents Summer Math Academy

Tennessee State University

PO. Box 9536

3500 John A. Merritt Blvd

Nashville, TN 37209-1561

(Late applications will not be considered) Over

Gender : O Male or O Female

Including you, how many people live in

your house? If you share time between multiple houses, please tell us how many people live in the house in which you spend most time.______________

Are you of Hispanic, Latino, or Spanish Origin?

O Yes

O No

Please specify your race (Select all that apply)

O White

O Black or African American

O Asian

O American Indian

O Alaska Native

O Native Hawaiian or Pacific Islander

What is your total household income?

O Less than $19,999

O $20,000 to $29,999

O $30,000 to $39,999

O $40,000 to $49,999

O $50,000 to $59,999

O $60,000 to $69,999

O $70,000 to $79,999

O $80,000 to $89,999

O $90,000 to $99,000

O $100,000 or more

Please indicate the highest level of education

achieved for each of the following individuals. If you do not have a relationship with one or more of these individuals, or if any of these individuals do not apply to you, please select Not Applicable

Mother

O Some high school

O High school diploma/GED

O Technical degree or certificate

O Completed some college but did not graduate

O 2 or 4 year College Degree

O Graduate Degree

O Not Applicable

Father

O Some high school

O High school diploma/GED

O Technical degree or certificate

O Completed some college but did not graduate

O 2 or 4 year College Degree

O Graduate Degree

O Not Applicable

Stepmother

O Some high school

O High school diploma/GED

O Technical degree or certificate

O Completed some college but did not graduate

O 2 or 4 year College Degree

O Graduate Degree

O Not Applicable

Stepfather

O Some high school

O High school diploma/GED

O Technical degree or certificate

O Completed some college but did not graduate

O 2 or 4 year College Degree

O Graduate Degree

O Not Applicable

Parent(s) Work Phone Number(s) Student E-mail Address

Personal Statement (Required with application)

SCHOOL OR COMMUNITY INVOLVEMENT

Parent E-mail Address(es)

COMPLETE THE FOLLOWING (information is required

for TBR and TSU statistical reporting purposes ONLY)

PERSONAL

INFORMATION

Parent(s) Cell Phone Number(s)

Are you interested in

pursuing a college degree?

Name two college majors that most interest you

(for example, Math, Biology, English, Chemistry etc).

Summer Math Academy

July 10 July 22, 2016 Think, Work, Serve

REFERENCES

Name of Reference (Math Faculty* ) Phone (Area and Number) E-mail

Name of Reference (Teacher/Principal/Asst Principal/Community Leader ) Phone (Area and Number) E-mail

Provide names and contact information for persons providing letters of reference. Reference letters must be received with application packet by Thursday, May 26, 2016.

AWARDS / HONORS

An applicant for this program MUST

1) be a sophomore (10th grade) or junior (11th

grade) in the fall term of 2016 (next year) and must currently be enrolled in high school;

2)provide a sealed transcript indicating a

minimum GPA of 2.75 (on a 4.0 scale);

3)have completed Algebra I.

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[PDF] Summer Math Academy Summer Math Academy program because…….

Summer Math Academy

July 10 July 22, 2016 Think, Work, Serve

Date of Birth:

Home/Local Phone

Student Cell Phone

Student Name (Last, First, Middle Initial)

Local Mailing Address

Parent/Guardian Name(s))

What grade will you be in

Favorite Course Subject(s)

For Office Use Only

DATE TIME

Notes:

Summer Math Academy program

Dr. John Robinson

Regents Summer Math Academy

Tennessee State University

PO. Box 9536

3500 John A. Merritt Blvd

Nashville, TN 37209-1561

Gender : O Male or O Female

Including you, how many people live in

Are you of Hispanic, Latino, or Spanish Origin?

O Yes

O No

Please specify your race (Select all that apply)

O White

O Black or African American

O Asian

O American Indian

O Alaska Native

O Native Hawaiian or Pacific Islander

What is your total household income?

O Less than $19,999

O $20,000 to $29,999

O $30,000 to $39,999

O $40,000 to $49,999

O $50,000 to $59,999

O $60,000 to $69,999

O $70,000 to $79,999

O $80,000 to $89,999

O $90,000 to $99,000

O $100,000 or more

Please indicate the highest level of education

Mother

O Some high school

O High school diploma/GED

O Technical degree or certificate

O Completed some college but did not graduate

O 2 or 4 year College Degree

O Graduate Degree

O Not Applicable

Father

O Some high school

O High school diploma/GED

O Technical degree or certificate

O Completed some college but did not graduate

O 2 or 4 year College Degree

O Graduate Degree

O Not Applicable

Stepmother

O Some high school

O High school diploma/GED

O Technical degree or certificate

O Completed some college but did not graduate

O 2 or 4 year College Degree

O Graduate Degree

O Not Applicable

Stepfather

O Some high school

O High school diploma/GED

O Technical degree or certificate

O Completed some college but did not graduate

O 2 or 4 year College Degree

O Graduate Degree

O Not Applicable

Personal Statement (Required with application)

SCHOOL OR COMMUNITY INVOLVEMENT

Parent E-mail Address(es)