Naamen Van / Name and Surname1

SCIMATHUS UNIVERSITY PREPARATION PROGRAMME
Stellenbosch University
APPLICATION for admissionto the programme in 2017

This form is also available in Afrikaans.

PLEASE READ THE INFORMATIONSHEET SO THAT YOU ARE FULLY INFORMED ABOUT THE SCIMATHUS PROGRAM. BY SUBMITTING THIS FORM WE ASSUME THAT YOU HAVE READ THE INFORMATION.

NO STUDENTS WITH MATHEMATICAL LITERACY WILL BE ACCEPTED.

(Please contact us at 021808 3032 if you do not have the information sheet. Alternatively, you may download it from:

  • Please complete this form in BLACK ink. All questions must be answered. Tick the boxes where you are asked to make a choice.

A. Student’s personal information

Identity number:
Surname: / Full names:
Which stream would you like to attend in SciMathUS?
(tick the box of your choice) / Mathematics and Physical Sciences / Mathematics and Accountancy
Date of birth: / Home language:
Race: / Gender: / Male / Female
Citizenship (please specify)
Your home address
(with postal code) and province / Your mobile numbers:
Your personal
e-mail address
Have you applied to a tertiary institution before? / If yes, at which institution?
If you have not been accepted, what was the reason?
Have you studied at a tertiary institution before? / If yes, at which institution?
If yes, when and what did you study?
If you have been issued a SU student number already, please provide that number:
What do you intend to study after SciMathUS?
Would you like to apply for accommodation at SciMathUS? Motivate your application in the space below. / Yes / No
How or where did you get to know about SciMathUS?
B. School information
Please submit certified copy of your NSC results or certificate as soon as possible
School where you matriculated / Matric examination number
Town/City / Province
Year in Grade 12 / Telephone number of school
Previous two schools (if applicable). Year(s) attended
Language of instruction / Afrikaans / English
Number of learners in your Grade 12 Mathematics class / Less than 20 / Between 21 and 30 / Between 31 and 40 / More than 40
Total number of learners in your school that took Mathematics in Grade 12 (the year that you were in Grade 12) / Less than 20 / Between 20 and 50 / Between 51 and 100 / More than 100
Your school fees per year / No school fees / Between R100 and
R 1500 / Between
R1 501 and
R5 000 / Between
R5 001 and
R10 000 / More than
R 10 000
Who was responsible for paying your school fees

School results of applicant(ALL MARKS MUST BE PROVIDED TO BE CONSIDERED FOR THE PROGRAMME)

(Marks will be verified with the school.)
Please state all subjects (Life Orientation excluded) taken by you as well as the performance marks (as a percentage) obtained in Grade 11 (final examination), Grade 12 (June examination), as well as the Grade 12 September examination in the table below.
NO STUDENTS WITH MATHEMATICAL LITERACY WILL BE ACCEPTED.
SUBJECTS / Gr 11 Final results / Grade 12 June / Grade 12 September
% / % / %
Home Language
Please specify the languages
1st Additional Language
Please specify the languages

C. Activities since completing Grade 12

This section must ONLY becompleted by applicants who matriculated in2015.

Activities during 2016:

Activity / Tick with a X / Name of institution/work place / Duration
Attended school
Studied on my own to rewrite certain subjects
Work
Studied at a tertiary institution
At home doing nothing
If you only studied at a tertiary institution for part of the year, why did you discontinue your studies?

If you have studied at another university or any other tertiary institution and withhold this information, your participation in SciMathUS will be terminated immediately, once this becomes known.

D. Details of your parent(s) or guardian

Father (or guardian) / Mother (or guardian)
Title:
Initial(s) and surname
Occupation / Job description
Home address:
Home telephone number
Mobile number
e-mail address
Marital status of parents / guardian(s) / Unmarried / Married / Widower/
Widow / Divorced / Separated

Please indicate the highest qualification of both parents or guardians with an X. (If the parent is a single parent, please indicate for the specific parent):

Father / Mother / Guardian / If applicable, what type certificate , diploma,
B-tech-degree or University-degree
Grade 11 (st. 9) and lower
Grade 12 (Matric)
Certificate, diploma of B-Tech degree
Degree (at any university)
If graduated, at which university?

E. Personal motivation (Maximum of 50 words per question)

Which factors at school, do you think, influenced you not performing well in Mathematics and Physical Sciences or Accounting?

Which factors at home, do you think, influenced you not performing wellin Mathematics and Physical Sciences or Accounting?

Why should we consider you for the ScimathUS programme?

What is your greatest achievement (academic or personal) and why do you say so? Tell us about a time when you, despite setbacks, persevered in order to achieve a goal.

F. Financial information

Parents/guardians of applicants must please complete this section.We remind you that only fully completed application will be considered. This includes this section. Certified copies of supporting documents must be submitted or faxed with the application (see Information sheet) to verify your family’s financial situation.Please put the applicant’s name and surname on all documents.

FULL NAME APPLICANT
Name
List yourself, your spouse, the applicant and then the other dependents. / Relation
Husband, wife, son, etc. / Age Please state:
adult, preschool, school or tertiary / Description of incomeeg. Salary, Pension, Child grant, Investment Interest, Business profit, etc. / Income per month
Please supply PROOF / Number of months per year for which this income is received. / Income per year.
Total number of family members dependant on income
(eg. Adults 2, Tertiary 1, etc.) / Adults (grand parentsetc) / Students stuying on a tertiary level / School-going children / Preschool children
Are any dependants listed in the table above, not part of your immediate family? / Yes / No

Ifyes, name thoseand state whythey are financiallydependentonyou.

Name / Reason
IMMOVABLE PROPERTY of the family : House, farm, etc. / Market Value / R / Bond outstanding / R
Please provide the information of other family members currently studying at this or another tertiary institution.
This information will only be considered if proof of registration has been received by 1 March 2017.
Name / Student number / Tertiary institution
G. Checklist

This application will ONLY be considered for selection if ALL the fields (spaces) are completed and if ALL supporting documents have been submitted. Incomplete applications will be ignored.

Use the checklist below to make sure that you submitthe following certified supporting documents with this application.

Please make sure that the applicant’s name and surname are on all documents.

Checklist / Tick this box when you attach the document.
1 / A certified copy of your ID.
2 / Certified copies of financial statements of your parents/guardians. Please read the section on the information sheet to ensure that the correct documentation is attached.
3 / Matriculants of 2016:
A certified copy of your final matric results should be faxed to 086 6964 752 as soon as you receive it in January 2017
4 / Matriculants of 2015 (if applicable to you):
A certified copy of your final matric certificate of 2015. If you have re-writen any subjects in 2016, please also submit those results.
H. Declaration by parent/guardian and applicant
Confirm or negate the following statement:
I / we, the undersigned, hereby declare that
  • The information supplied in this application form is true and correct.
  • I am / we are fully aware of the fact that this is a selection programme where a selection process will be followed and that my child/ I may not be selected for the programme, in spite of meeting the minimum entry requirements.
  • I am fully aware of the fact that this programme is situated at an academic institution where research is part of the programme. My child / I may be asked to participate in this research from time to time.
  • I give consent that pictures of my child/ me as a student may be used for marketing purposes i.e on the web site, social media, posters, brochures etc.
  • I am / we are aware of the compulsory additional Mathematics classes, offered from mid to end November 2017, to assist students to prepare for university Mathematics.
  • Furthermore, I / we give permission that my / our personal information may be supplied to companies for bursary application purposes where applicable.

Please mark your response with X in the appropriate block: / Yes / No
Signature of applicant / Date
Signature of Parent/Guardian / Date