STEM Center Application

Please answer all sections of the application. Your responses are necessary to determine program eligibility and will be kept confidential.

January 2019 Workshop

Do you intend on participating in the January 2019 Workshop?

Sam ID and D.O.B.
Full Name
Local Address/Dorm Address
Permanent Address
Contact Information
Personal Information
Gender
Ethnicity
Race




Status

Are you a U.S. Citizen or Permanent Resident?

Are you a U.S. Military Veteran?

First-Generation Information

Does your natural or adoptive mother have a Bachelor's Degree?

Does your natural or adoptive father have a Bachelor's Degree?

If you did not reside with or receive support from a natural or adoptive parent, were you a:






Disability Information

Do you have a diagnosed physical or mental impairment that substantially limits your ability to participate in educational experiences and opportunities offered by SHSU?

If yes, are you registered with Disability Services Office on campus?

Education Information
Classification

Fall 2018 I will be a:




Are you a transfer student?

Did you graduate high school?

Did you receive a G.E.D.?

Personal Statement

Answer the prompt below (250 words or less)

Consent to Release and Services Contract

I understand that The STEM Center needs access to my personal and academic information in order to provide the best possible support for me at Sam Houston State University. Therefore, I agree to release such information to the STEM Center staff members for as long as they are required by federal regulations to track and report my academic progress to the U.S. Department of Education. I further understand that all released material will remain confidential. Academic information and disability verification, however, will be shared with faculty, university departments, the coordinator for services to students with disabilities, and appropriate representatives of the U.S. Department of Education only as necessary.

I hereby give the STEM Center program permission to obtain information regarding my academic status, including progress reports from course instructors. I grant permission for the STEM Center to access my academic information for the purpose of evaluating my application. If I identify a disability, I grant permission to release necessary information to STEM Center staff for the purpose of verifying eligibility.

I agree to allow my name and/or picture to be printed in any STEM Center newsletter, publication, or display in recognition of academic success, leadership, or graduation.

I agree that data received from participation in surveys, evaluations, seminars, and financial literacy modules may be used for evaluative and research purposes for STEM Center and collaborating SHSU Departments.

I agree to meet the following criteria for the time that I will be with the STEM Center:

  • I agree to maintain contact with STEM Center staff throughout the year.
  • I agree to utilize all of the services that the STEM Center offers to me.
  • I agree to keep STEM Center informed about any changes in my name, address, phone number, email address, and any other important information.

I understand and agree to each of the above responsibilities and privileges.

By my signature, I certify that I have read and understood the information on this page and that I am capable of giving such consent and do so voluntarily.

Are you under 18 years of age?