Name ______

Last name / First Name / Middle Initial
Address / City / State / Zip
College or University / Department
Telephone / Email / Student ID / Cumulative GPA
Enrollment status / Full-time / Part-time
Class / First-year / Sophomore / Junior / Senior
Gender / Male / Female
Ethnicity / Hispanic or Latino / NOT Hispanic or Latino / Not reported
Race
Check all that apply / Alaska Native
Asian
Black or African American
Native American / Native Hawaiian or Other Pacific
Islander
White
Not reported or Unknown
Disability Status: / Hearing Impairment
Visual Impairment
None / Mobility or Orthopedic Impairment
Other
Not reported
Citizenship / U.S. citizen / Permanent resident / Temporary resident
Major or Interest (choose one) / Agricultural Science
Chemistry
Computer Science
Engineering
Environmental Science / Geosciences
Life or Biological Sciences
Mathematics
Physics or Astronomy
Non-STEM
Are you receiving financial support in the ’11-‘12 academic year? / Yes / No
Have you completed a FAFSA for ’11-‘12 academic year? / Yes / No
What aspects of undergraduate education thus far do you think are the biggest challenges to your goal of earning a bachelor’s degree? Why?
How might the North Star STEM (science, technology, engineering and math) Alliance best address your needs? What programs or services would best support your challenges?
In what ways are you committed to the goal promoting multicultural student participation in STEM?
Authorization for Photography:
(initial) I hereby expressly grant the University of Minnesota, lead institution of the North Star STEM Alliance, the right to make, use, and/or publish information, photographs, or any other reproduction of my physical likeness for various communication efforts such as pamphlets, booklets, video tapes, audiotapes, slide shows or internet sites. In addition, I expressly grant this right to be used for educational, marketing, and/or promotional purposes.
How This Information Will Be Used: The information you submit on this form will be used by college/university officials and other Alliance administrators to evaluate your eligibility to become a scholar, evaluate program effectiveness, and report data to the National Science Foundation (NSF) for evaluation of overall program effectiveness. Please be assured that gender, race, ethnicity and disability status information will not affect your eligibility to become a fellow, but the NSF requires the collection of this information as a condition of program funding.
As a scholar, information about your participation in program events will also be provided to the NSF at the end of the year, which is a prerequisite for you to be eligible for a stipend. If you wish to claim a stipend for your participation in the program, you will be required to submit your SSN, which will be provided to tax officials in order to process the payment. Please contact your site coordinator if you have questions about the application process or information handling.
Signature / Date / Academic year
2011-2012

If you have completed 60 or more undergraduate credits, please attach a copy of your current resume. Return this application to the site coordinator at your college or university. Contact information is located at www.northstarstem.org under partner organizations.