STUDENT APPLICATION FORM 2016

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1 Verizon Minority Male Maker Program Directed by Central State University STUDENT APPLICATION FORM 2016 Central State University, Wilberforce, OH June 19-July 1, 2016 Camp and once monthly sessions during school year Camp Information The Verizon Minority Male Maker Program is designed to provide learning activities, experiments, projects, and field experiences for minority male students entering 6 th, 7 th, or 8 th grade in the fall of Scholarships are available for 40 students. The Verizon Minority Male Maker Program begins with a two-week, residential academic camp. This will be followed by activities at CSU s main campus in Wilberforce, OH, one Saturday a month. The camp will provide youth with instruction, professional development, leadership skills, civic engagement and mentoring activities that prepare young people to make a positive impact in their communities. Participating students will experience major areas of STEM courses such as Robotics, Mobile Application Development, 3D Printing, Entrepreneurship, etc. Field trips to industries will be part of the camp. Selection criteria will include student s GPA, having an interest in STEM related careers, letters of recommendations and a student essay. Success will be recognized. A stipend of $100 will be awarded upon the completion of milestone events as follows: $50 upon successful completion of Summer Camp. $50 upon completion of the school year. A Tablet will be provided upon successful completion of the full program. The camp will be held on the campus of Central State University, 1400 Brush Row Rd, Wilberforce, Ohio Students will be housed in a dormitory on the university s campus for the two week camp portion of the program. Application Process A completed application packet will contain the following: Parent/Guardian and student complete student application form. Teacher recommendation forms. Student to write a one (1) page essay. Completed Registrar s form returned in a sealed envelope to Parent/Guardian for return with packet. Please note, your application will not be considered complete until all items have been received by the university. The above requested documents are to be sent to Central State University/Verizon Minority Male Maker Program, Attention: Dr. Abiodun Fasoro, PO Box 1004, Jenkins Hall, Wilberforce, OH The Student Application Form, Records and Recommendations are due by MAY 25, All requested documents MUST be returned together. If we have not received all requested documents by the deadline date, the application will not be considered. Selections for the Verizon Minority Male Maker Program will be made on or around June 1, You will receive written notification about the status of the application on or around June 1, If you have any questions or need additional information, please contact Ms. Suzanne Marie at INCOMPLETE APPLICATIONS MAY NOT BE CONSIDERED

2 KEEP THIS PAGE FOR YOUR REFERENCE Application Process The application consists of four sections: 1. Student Application Form 2. Recommendation Forms 3. Student Essay 4. Student s School Records Verizon Minority Male Maker Program Directed by Central State University June 19 July 1, 2016 and once-monthly Saturday sessions during school year Central State University, Wilberforce, Ohio Student School Records are to be requested from the school registrar by the parent/guardian and submitted with all other documents listed above. All items must be sent together and postmarked by May 25, 2016 for the student to be considered for a scholarship to attend the Verizon Minority Male Maker Program. Please mail completed application packet to: Central State University/Verizon Minority Male Maker Program, Attention: Dr. Abiodun Fasoro, PO Box 1004, Jenkins Hall, Wilberforce, OH Or scan and the completed packet to Incomplete applications MAY NOT be considered. If all requested documents have not been received by the deadline date, the application may not be considered. Families will receive written notification on the status of the student s application on or around June 1, If you have questions or need additional information, contact Ms. Suzanne Marie at Purpose: The Verizon Minority Male Maker Program is designed to provide minority males in middle school with education, experience and mentoring activities that prepare them to make a positive impact in their communities. Program: The Verizon Minority Male Maker Program is a two-week academic, residential camp followed by once a month Saturday instructional sessions. Participating students will experience major areas of STEM courses such as Robotics, Mobile Application Development, 3D Printing, Entrepreneurship, etc. Field trips will be part of the camp. Camp Location: The camp will be held on the Central State University campus in Wilberforce, Ohio. Housing and meals will be provided by the university. Parents/Guardians are responsible for their student s transportation to and from the program. Check List of Application Requirements Due May 25, 2016 (1) Student Application, 2 pages fully completed and signed by parent/guardian and student (2) Recommendation Forms (3) Student Essay (4) Student School Records Mail Completed Application to: Central State University Attn: Verizon Minority Male Maker Program, Dr. Abiodun Fasoro, PO Box 1004, Jenkins Hall, Wilberforce, OH OR scan and completed packet to

3 Verizon Minority Male Maker Program STUDENT APPLICATION FORM 2016 APPLICATION DEADLINE IS MAY 25, 2016 Please print CLEARLY in blue or black ink or type Name of student: Home address: City State Zip Code Ethnicity: of Birth (Month/Day/Year) / / Gender (check one): Female Male T-Shirt Size: Small Medium Large X-Large XX-Large PLEASE INDICATE WHETHER YOUTH OR ADULT SIZE Name of school student is currently attending: Current Grade Level: School District: Name of School student will be attending during the academic year: School District: School Address: Please list school organizations, any science and/or mathematics activities (Science Fair, math club, after school programs, summer programs, etc.) you have participated in 2013, 2014, Include awards received and offices held. You may attach a separate sheet, if needed.

4 Name of Student: Telephone Number: Please list any community activities and/or community groups that you have been a part of. Please list any other activities or achievements that you would like to share with the selection committee. Student s Essay Describe in 3 to 5 sentences why you are interested in the Verizon Minority Male Maker Program and why you would be a good candidate for the program. Please print clearly. Statement Of Commitment I commit to attending each session of the program, completing any assignments in a timely manner and to participate fully in the instructional sessions and other activities. I commit to holding a positive attitude and working as a good team member. I realize that this is a valuable opportunity and I want to gain as much from this experience as possible. Signature of Student Name of Student

5 PARENT/GUARDIAN INFORMATION Instructions: Please complete the following information for at least one custodial parent or guardian, both, if available. I commit to supporting my son in this program, providing transportation to and from the sessions and supporting his completion of the full program, including the Saturday sessions during the school year. Name of Parent(s) or Guardian(s): Daytime Phone No: Home Phone No: Cell Phone No: Address: Signature of Parent or Guardian Name of Parent or Guardian: Daytime Phone No.: Home Phone No.: Cell Phone No.: Address: Signature of Parent or Guardian

6 Verizon Minority Male Maker Program At Central State University, Wilberforce, Ohio REQUEST FOR RECORDS This form is to be given to the registrar at your son s school. A parent or guardian must sign this request first so that the registrar can release the records. Dear Registrar: Please forward a copy of official records for this student to the parent/guardian (grades and standardized test scores). The records should include a copy of the most recent grades/report card and standardized test scores. This form should accompany the records. (Please print) Name of Student: Student ID Number: School Name: School Telephone Number: School Address: Grade: Birth : Homeroom Teacher: I hereby grant permission for the release of the information requested. Signature of Parent/Guardian Signature of Parent/Guardian

7 Recommendation from Current SCIENCE Teacher For a Student applying for the Verizon Minority Male Maker Program 2016 Central State University Name of Teacher: Address: Teacher s Telephone Number: Directions to Teacher: The student who has given you this form is applying to attend the Verizon Minority Male Maker Program this summer and through the upcoming school year. As a teacher of this student, you will be able to provide valuable information for our consideration in the student s application to attend this program. This program includes a two-week residential camp and Saturday instructional sessions during the school year. Please complete the chart below and include your letter of recommendation for this student. To assure confidentiality, please place this completed form along with your letter in an envelope, seal it, and write your name across the sealed flap. Please return the sealed envelope to the student/parent or guardian as soon as possible. Students/Parents or Guardian are responsible for returning completed application. Thank you for your assistance. Please Note: If you are interested in teaching in our program, please for further information. Name of Student: Course taken with this teacher: Subject Year Please put an X in the appropriate column for each of the following statements: Statements: This student was eager to learn This student cared about other students This student was late to class This student skipped classes This student turned in homework and projects on time This student participated in class and group activities This student participated in co-curricular activities (science fair, etc.) This student volunteered to help other students This student was an asset to the class Very much Often Sometimes Rarely Never Check the best answer to the following question: Would you like to teach this student in another class? Yes, definitely Maybe Definitely not Check the box if you would you recommend student to participate in the Summer Science Camp Please include a brief paragraph on the back of this page concerning your recommendation for this student s participation in the program.

8 Recommendation from Current MATHEMATICS Teacher For a Student applying for the Verizon Minority Male Maker Program 2016 Central State University Name of Teacher: Address: Teacher s Telephone Number: Directions to Teacher: The student who has given you this form is applying to attend the Verizon Minority Male Maker Program this summer and through the upcoming school year. As a teacher of this student, you will be able to provide valuable information for our consideration in the student s application to attend this program. This program includes a two-week residential camp and Saturday instructional sessions during the school year. Please complete the chart below and include your letter of recommendation for this student. To assure confidentiality, please place this completed form along with your letter in an envelope, seal it, and write your name across the sealed flap. Please return the sealed envelope to the student/parent or guardian as soon as possible. Students/Parents or Guardian are responsible for returning completed application. Thank you for your assistance. Please Note: If you are interested in teaching in our program, please for further information. Name of Student: Course taken with this teacher: Subject Year Please put an X in the appropriate column for each of the following statements: Statements: This student was eager to learn This student cared about other students This student was late to class This student skipped classes This student turned in homework and projects on time This student participated in class and group activities This student participated in co-curricular activities (science fair, etc.) This student volunteered to help other students This student was an asset to the class Very much Often Sometimes Rarely Never Check the best answer to the following question: Would you like to teach this student in another class? Yes, definitely Maybe Definitely not Check the box if you would you recommend student to participate in the Summer Science Camp Please include a brief paragraph on the back of this page concerning your recommendation for this student s participation in the program.

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