Cypress College STEM² Program Application

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Melina Johnston
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1 Academic Year ********************************************************************************* INSTRUCTIONS Complete this application thoroughly and submit ONLINE OR IN PERSON. Make sure to include a copy of all your unofficial transcripts; that is, all colleges you have attended. In addition, please include a copy of your financial aid award, which you can access on My Gateway. Make sure to sign your application. THIS IS A FILLABLE APPLICATION. PLEASE TYPE YOUR INFORMATION. Handwritten applications will NOT be accepted. Completed applications may be submitted to SEM 211 or SEM 212. Address questions or concerns to: Yanet Garcia, STEM² Program Director 9200 Valley View St, Cypress, CA Cypress College, SEM 103 ygarcia@cypresscollege.edu Rosa Mejia, STEM² Program Coordinator 9200 Valley View St, Cypress, CA Cypress College, SEM 212 rmejia@cypresscollege.edu Please Note: We appreciate your interest in applying to the STEM Program. In an effort to get to know you better as a prospective STEM Scholar, you are required to complete all the information requested on the application. ***Incomplete applications will not be considered.*** We look forward to reviewing your application!

2 Application submitted in person: Can be collected in our Science Engineering & Math building in room SEM 211 or SEM 212. Application submitted online: Please carefully read the instructions below:

3 Academic Year Last 4 digits of Social Security #: Campus/Student ID First Name: Middle (or initial) Last Name: Permanent Address: Current Mailing Address (if different): City: State: Zip: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Birth date: / / Gender: Ethnicity: (1) (2) If you are American Indian or Alaskan Native, what is your Tribal Affiliation? Is a language other than English spoken regularly in your home? (Yes or No) If yes, specify: _ Residential Status: US Citizen Permanent Resident F1 Visa _ Resident Alien Semester and year first enrolled at Cypress College: / Total number of college units completed: 0-29: _ 30-60: 60+ Current cumulative GPA: Highest level of college math passed: Declared Major: Courses currently enrolled in: Intended Transfer College(s): Prospective semester and year of transfer: / Previous school(s) attended: High School: Dates: College: Dates: College: Dates: Obstacles that may interfere with your education: (check all that apply): o Financial need o Employment issues o Family obligations o Knowledge of educational system o Exceptional needs (specify below) Are you employed? Yes No If yes, how many hours per week? What is the highest level of education achieved by each of your parent(s)/guardian(s)? (Please indicate by using a letter) Father Mother What type of work have your parent(s)/guardian(s) typically done over the past years prior to retiring? (Please indicate by using a letter) Father Mother A. No school/elementary school B. 8 th grade or less C. Some high school K. Don t Know D. High school graduate E. Some college/university F. Community college degree G. 4-year college degree H. MS/MA/MBA/Ph.D. I. Other A. Never employed B. Farm Worker C. Business Administration D. Retail/Sales/Clerical E. Mechanic F. Professional degree (law, medical, etc.) G. Teacher/Professor H. Skilled Tech-Med, Trade I. Engineer/Computer Scientist J. Don t Know K. Professional (Doctor, Lawyer, etc.) L. Factory Worker M. General Laborer N. Other

4 Please type a word essay answering the following two questions: 1). Why do you want to join the STEM 2 program? 2). What do you believe you can contribute to the STEM 2 program?

5 STUDENT CONTRACT If you are determined eligible for the STEM 2 Program, you are agreeing to follow the student contract below. THE FOLLOWING STUDENT CONTRACT IS PART OF YOUR ELIGIBILTY REQUIREMENT FOR THE STEM 2 PROGRAM. Please read the contract thoroughly in order to fully understand what will be expected of you as an active STEM 2 Scholar. What the STEM Program can offer you: 1. Provide advising and counseling 2. Provide academic excellence workshops and access to the STEM Study Lounge to assist in math, science, and engineering courses 3. Assist you with applications for scholarships and fellowships 4. Assist you in obtaining summer, part-time, or full-time research 5. Assist you with all transfer requirement to a four-year university 6. Assist you in securing internships and summer enrichment programs Student Expectations: 1. Understand the importance of getting involved in student organizations for your academic and professional career development 2. Understand that the study of math, science, and engineering requires your education to be your number one priority 3. Develop good study habits (by attending our workshops, supplemental instruction, etc.) to improve and maintain your grades Agreement/ Personal Information Release: 1. I will notify STEM 2 of any changes in my name, address, or phone number 2. I agree to follow the suggested educational plan designed by STEM 2 3. I will attend a minimum of 2 STEM workshops including 1 STEM Club activity OR attend a minimum of 3 STEM Workshops every semester. 4. I will attend our monthly STEM family group meetings every semester. 5. I will notify STEM 2 of my class schedule every semester 6. I will notify STEM 2 if I fall below a 2.5 grade point average 7. I agree to see my STEM counselor at least once a semester I give permission for STEM 2 to give my name, phone number, and address to college and employer representatives, and use my photograph in STEM 2 and college promotional materials. Yes No By applying to the STEM 2 Program, I understand that I give permission for STEM 2 to obtain information about my performance from colleges and testing agencies, financial aid and other offices to determine eligibility for the STEM 2 program. You may be asked to provide additional information for eligibility determination. I certify that I have provided true and correct information. STEM 2 Applicant Name Date If under 18 years of age, parent or guardian first and last name Date STEM 2 Counselor Signature Date STEM 2 Director Signature Date

6 Academic Year 2016/2017 PLEASE COMPLETE ALL ITEMS Criteria Questionnaire: Answer the following questions as thoroughly as possible. 1). Are you a first- generation college student? *A student whose parent(s)/legal guardian(s) did not complete a bachelor s degree in the United States. 2). Are you receiving financial aid? (Access information on MyGateway) 3). Are you in EOPS? 4). Are you a Veteran student? 5). Are you currently in the Honors Program? 6). Are you a Student Athlete? (In accordance to California Community College Athletic Association.) 7). Are you an AB540 student? Yes No If yes, do you have a work permit? 8). Are you an International student? 9). Are you in Disability Support Services (DSS)? Please list any volunteer activities you participate in:

7 Academic Year 2016/2017 PLEASE COMPLETE ALL ITEMS Please Note If you are selected to participate and benefit from the STEM 2 program at Cypress College, you agree and commit to the following activities per semester. 1. Meet with a STEM counselor at least once a semester 2. Maintain a GPA of at least Participate in 2 STEM workshops AND one STEM Club activity OR participate in a total of 3 STEM Workshops 4. Attend the once a month meetings with your assigned STEM Family Group. 5. Apply to at least one scholarship, summer research, or internship experience per semester 6. Create a professional profile on LinkedIn for networking purposes STUDENT NAME DATE Last four digits of Social Security #: Student ID #: I certify that I have truthfully answered each of the questions that pertain to the Academic Eligibility criteria for STEM 2. In addition, I understand that I cannot take part in the STEM 2 Program if I do not meet the criteria and/or if I have not answered truthfully to any and all of the above-referenced questions. STUDENT NAME DATE

8 Academic Year 2016/2017 Student Checklist: To ensure your application is accepted, please review the checklist to verify all required documents are included in your submission. Note: This page does not need to be submitted and is for informational purposes only. 1) STEM Program Application (Application must be typed) 2) Unofficial Transcripts from all colleges attended, including Cypress College. If this is your first semester at Cypress College, please include a current semester schedule and other transcripts, if applicable. 3) Financial Aid Award Summary. Submit your financial aid award summary from MyGateway. If you do not receive financial aid, please submit what is listed on your MyGateway account.

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