For Office Use Only
Student Achievement, Retention, & Success
Date Application Received
Tennessee State University
3500 John A. Merritt Boulevard/P.O. Box 9555
Nashville, Tennessee 37209-1561
SUMMER SUCCESS INSTITUTE
Application for SOPHOMORES & JUNIORS
Name
S SN
Address
Street
City
Phone
State
Zip
Date of Birth
High School Attended
Anticipated Date of Graduation
E-mail
High School courses consisted of:
College preparatory courses
Vocational courses
I understand that “Students shall be subject to all rules and regulations of the University and the Tennessee Board of
Regents” (TSU Student Handbook). Failure to comply with rules and regulations will result in immediate
expulsion from the program.
Student Signature
To Be Completed by Parent
I,
, give my permission for my child (name listed above) to participate in the
Parent/Guardian
Summer Success Institute. I understand that housing, food, and transportation will not be provided by Tennessee
State University and that my son/daughter must abide by all rules and regulations of TSU and the Tennessee
Board of Regents to participate.
Parent Signature
To Be Completed by High School Counselor
This is to verify that the above named student has taken the ACT/SAT and the scores are indicated below. This is
to also determine if the student has taken or is currently enrolled in Algebra 1 and/or 2.
ACT Scores:
English
SAT Scores:
Verbal
Algebra 1 Completed: Yes
Currently Enrolled
Math
Math
No
Composite
Critical Reading
Algebra 2 Completed: Yes
Currently Enrolled
No
High School Guidance Counselor Signature
Mail to: TSU, 3500 John Merritt Blvd., P.O. Box 9555, Nashville, TN 37209
OR
FAX to: (615) 963-5566