Florida Gulf Coast University, Fort Myers, Florida
Office Community Outreach Programs
National Association for the Advancement of Colored People
FGCU-NAACP Pre-Collegiate STEM Academy
10501 FGCU Blvd South; Fort Myers, FL 33965-6565
Contact: Anthony Hyatt, Senior Coordinator of Community Outreach, Modular 3, Florida Gulf Coast University
Email:[email protected], Phone: 239-590-1034
Application for FGCU-NAACP Pre-Collegiate STEM Academy (June 19th – July 1st 2016)
DEADLINE: Friday, April 15th 2016
Application Check List
High School Official Transcripts
Recommendation Forms (2)
STUDENT INFORMATION
Last Name
First Name
Middle Name
Address
City
(
State
)
(
Home Phone
ZIP
)
Cell Phone
Students Date of Birth (Month / Day / Year)
*Student’s Email Address
_________________________________________________________(____)___________________________
Parent/Guardian’s Name (please print)
Contact number
*Parent/Guardian Email Address
Are you a U.S. Citizen? __Yes __No
Do you have a valid passport? __Yes ___No
WHICH RACIAL/ETHNIC GROUP BEST DESCRIBES YOU:
o
American Indian/Alaskan Native
o
Asian or other Pacific Islander
o
Black or African American (not Hispanic)
o
Hispanic or Latino
o
White (not Hispanic)
o
Other ______________________
o
SEX:
Male
Female
(PLEASE CIRCLE THE APPROPRIATE SEX)
1 of 2
ACADEMIC INFORMATION
High School: ______________________________
Current GPA: _______ / _______
1.
Circle Present Grade Level: 9
10
11 12
SAT and/or ACT score (if available):
What extra-curricular activities do you participate in?
2.
Do you feel your grades in high school; so far, accurately reflect your work and your abilities?
3.
What are your two (2) favorite subjects and why?
4.
Why do you want to participate in the FGCU-NAACP Pre-Collegiate Summer Camp?
Parent/Guardian’s Signature:
Feel free to use a separate sheet
Date:
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