Summer Math Academy
July 10 – July 22, 2016
Think, Work, Serve
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)
PERSONAL
INFORMATION
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
For Office Use Only
DATE
COMPLETE THE FOLLOWING (information is required
for TBR and TSU statistical reporting purposes ONLY)
TIME
Please specify your race (Select all that apply)
O White
O
O
O
O
O
Student Name (Last, First, Middle Initial)
Local Mailing Address
Black or African American
Asian
American Indian
Alaska Native
Native Hawaiian or Pacific Islander
Date of Birth:
City
Home/Local Phone
Student Cell Phone
State
Zip
O
O
O
O
O
O
O
O
O
Parent/Guardian Name(s))
Student E-mail Address
Parent(s) Work Phone Number(s)
Favorite Course Subject(s)
Parent(s) Cell Phone Number(s)
What grade will you be in
next school year (Fall 2016)?
Grade Point Average GPA
Are you interested in
pursuing a college degree?
Name two college majors that most interest you
(for example, Math, Biology, English, Chemistry etc).
SCHOOL OR COMMUNITY INVOLVEMENT
Please list all campus/community organizations and any offices held
Mother
O Some high school
O
O
O
O
O
O
O
High school diploma/GED
Technical degree or certificate
Completed some college but did not graduate
2 or 4 year College Degree
Graduate Degree
Don’t Know
Not Applicable
Father
O Some high school
Campus/Community Organization
Office Held
Campus/Community Organization
Office Held
Campus/Community Organization
$20,000 to $29,999
$30,000 to $39,999
$40,000 to $49,999
$50,000 to $59,999
$60,000 to $69,999
$70,000 to $79,999
$80,000 to $89,999
$90,000 to $99,000
$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
Parent E-mail Address(es)
Name of High School
What is your total household income?
O Less than $19,999
O
O
O
O
O
O
O
High school diploma/GED
Technical degree or certificate
Completed some college but did not graduate
2 or 4 year College Degree
Graduate Degree
Don’t Know
Not Applicable
Office Held
Stepmother
Notes:
Personal Statement (Required with application)
On a separate sheet of paper, complete the following
statement in 100 words or less:
I should be chosen to participate in the TSU Regents
Summer Math Academy program because…….
O
O
O
O
O
O
O
O
Some high school
High school diploma/GED
Technical degree or certificate
Completed some college but did not graduate
2 or 4 year College Degree
Graduate Degree
Don’t Know
Not Applicable
Stepfather
O Some high school
O
O
O
O
O
O
O
High school diploma/GED
Technical degree or certificate
Completed some college but did not graduate
2 or 4 year College Degree
Graduate Degree
Don’t Know
Not Applicable
Over
Summer Math Academy
July 10 – July 22, 2016
Think, Work, Serve
REFERENCES
Provide names and contact information for persons providing letters of reference.
Reference letters must be received with application packet by Thursday, May 26, 2016.
Name of Reference (Math Faculty* )
Name of Reference (Teacher/Principal/Asst Principal/Community Leader )
Phone (Area and Number)
Phone (Area and Number)
E-mail
E-mail
AWARDS / HONORS
ELIGIBILITY
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.
4) provide evidence of “no disciplinary action”
taken against them by the school in the past
year (provided by school counselor or
administrator)
5) submit a complete application with student
personal statement and at least two
recommendation letters (incomplete
applications will not be accepted)
One recommendation should come from a math
faculty and one from another school official or
community member (e.g. church, counselor, etc).
CONFIRMATION
I certify by signing this
application that the information
provided here is true. I
authorize the Tennessee State
University Regents Summer
Math Academy administration to
verify any information submitted.
Student Applicant Signature
Date
Parent/Guardian Signature
Date
Tennessee State University, a Tennessee Board of Regents institution is an Equal Opportunity/Affirmative Action University.
It is committed to education of a non-racially identifiable student body.