T-Stem Challenge Scholarship Application Form

BROOKHAVEN COLLEGE

T-STEM CHALLENGE SCHOLARSHIP APPLICATION FORM

Purpose

TheTexas Science, Technology, Engineering, and Mathematics (T-STEM) ChallengeScholarship Program at Brookhaven College, DCCCD,provides funding for high-achieving, eligible students pursuing a degree in the STEM field disciplines of biology, chemistry, geology, physics, math, engineering, computer science, orradiologic sciences.

Benefits

Students selected as T-STEM scholars will receive an opportunity to intern and explore careers and networkwith other STEM students, faculty, and industry professionals.

Students will be eligible for merit-based awards of up to $1,250 total over the academic year based on eligibility andparticipation criteria.

Requirements

Register with the Selective Service System or have a statement declaring exemption from Selective Service.

Graduate from high school with a least a 3.0 GPA on a four-point scale in mathematics andsciences courses.

Maintain a program of study with Brookhaven College in an approved STEM field listed above

Complete 30 credit hours for fall, spring, and summer and must be a full-time Brookhaven College student enrolled in at least 12 credit hours per long semester (fall and spring).

Agree to participate in enrichment types of activities by volunteering or interning in a STEM field-related area

Application Process

1. Complete the T-STEM application, T-STEM application questionnaire, and T-STEM scholarprofile and commitment agreement.

2. Provide an official, high school transcript and college transcript (if college hours have been earned).

3. E-mail, mail or deliver completed application packet including transcriptsto the following office:

BROOKHAVEN COLLEGE

Development Office

Attn: Ngoc Truong

3939 Valley View Lane

Farmers Branch, TX 75244

972-860-4182,

Decisions of the selection committee are final.

The T-STEM Challenge Scholarship Program is funded by a grant from the Texas Higher Education Coordinating Board.
T-STEM Challenge Scholarship Application Instructions

1. Please complete only the shaded areasof all sections.The non-shaded areas cannot be edited. When completed, please sign, initial where requested, date and submit to the office identified on the first page of this packet.

Applicant Information

Applicant First Name: Last Name:

DCCCD Student ID#: Date of Birth:

Home Address:

City: State: Zip:

Primary Phone: Secondary Phone:

Primary E-mail Address*:

*The “Primary E-mail Address” you provide here will be used as a central source of communications with Brookhaven College. You agree to check your primary e-mail to review any messages from the T-STEMprogram. You also agree to notify Brookhaven College immediately of any changes in your “Primary E-mail Address.”

Academic Information

Intended major: ChemistryGeologyPhysicsRadiologic SciencesBiologyMathEngineeringComputer Science

College credit hours earned to date:

High school GPA on a four-point scale in mathematics and sciences courses:

Have you registered with the Selective Services System? YesNo

Do you plan to complete a minimum of 30 semester credit hours within a year(fall, spring, and summer semesters or equivalent)?YesNo

Have you been a STEM scholar before? YesNoIf so, list year and semesters:

Do you intend to graduate from Brookhaven or transfer before earning your degree? Please choose one answer:

I plan to graduate from Brookhaven College

I plan to transfer before I earn an Associate Degree

Your answer is used for informational purposes and will not impact the decision of the selection committee
Authorization Information

______

(Initial)

I release to the Dallas County Community College District (DCCCD) and Brookhaven College T- STEMChallenge Scholarship program the right to access all my current and ongoing personal and academic records and transcripts. If awarded a scholarship, I understand that I must meet the awardcriteria and standards of academic progress for the DCCCD and the Brookhaven College T-STEMChallenge Scholarship program.

______

(Initial)

I understand my name and information from my academic history may be released to the selection committee andthe award donor. If granted an award, I release to the DCCCD and Brookhaven College T-STEM Challenge Scholarship program the rightto use my name, story, and picture for printed and video materials, reports, and press releases,without compensation, as well as relatedrecognition ceremonies and receptions.

I certify that the statements herein are true to the best of my knowledge and grant my permission for the information containedherein to be shared with the selection committeeand award donor.

Student Signature:______Date: ______

T-STEM CHALLENGE SCHOLARSHIP

APPLICATIONQUESTIONNAIRE

Please limit each of your answers to 250 words.

1. What are your STEM career goals?

2. Describe the reasons for your interest in a STEM field.

3. What do you hope to accomplish as a professional in a STEM field?

4. What would be most valuable to you as a STEM scholar and why?

T-STEM CHALLENGE SCHOLARSHIP PROFILE AND COMMITMENT AGREEMENT

T-STEM CHALLENGE SCHOLARSHIP PROFILE INFORMATION

(Please enter your information in the shaded areas only.)

Name: Student ID#:

Phone Number(s):

Primary E-mail Address:

Declared STEM field: ChemistryGeologyPhysicsRadiologic SciencesBiologyMathComputer ScienceEngineering

Will you be employed during the academic year? YesNoIf yes: Full-timePart-time

Are you receiving financial aid or any additional awards during the academic year?YesNo

If yes, please list here (examples: Pell, Rising Star, etc.):

T-STEM SCHOLAR COMMITMENT AGREEMENT

Please review the requirements of the T-STEM program listed below. Then, initial next to each item as anacknowledgment of your commitment to satisfy each requirement. Failure to meet these requirements will resultin a reduction or loss of award.

_____ I will maintain a program of study with Brookhaven College in an approved STEM field.

_____ I have a 3.0 GPA or higher on a four-point scale in high school mathematics and science courses, and I agree to maintain a cumulative 3.0 GPA or higher throughout the academic year.

_____ I plan to complete a minimum of 30 credit hours within a year (fall, spring, summer semesters or equivalent).

_____ I understand that failure to meet these requirements will result in a reduction or loss of my award.

_____ I understand that, if I amawarded the T-STEM scholarship, itmay affect other financial aid awards I receive.For example, my student loans and/or work study may have to be reduced. Depending on my financial aid eligibility, my T-STEM scholarship, if I am awarded one, may be reduced. Receipt of this award will not affect my Pell scholarship, if I qualify for one.

Student Signature:______Date:______

T-STEM CHALLENGE SCHOLARSHIP APPLICANT CHECKLIST

Use this drop-down menu checklist to make sure that you submit all of the necessary T-STEM application packet documents.

CompletedNot completedApplication Form

CompletedNot completedApplication Questionnaire

CompletedNot CompletedScholar Profile and Commitment Agreement

CompletedNot CompletedOfficial High School Transcript AND College Transcript (if college hours have been earned)

Submit all of the above to the following office:

BROOKHAVEN COLLEGE

Development Office

Attn: Ngoc Truong

3939 Valley View Lane

Farmers Branch, TX 75244

972-860-4182

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