North Carolina Mathematics and Science Education Network



NC-MSEN PCP Senior Survey Form

Please complete ALL items.

Last Name

First Name Middle Initial



PCP Site

SSN - only the last 4 digits (9999) Birth Date (mm/dd/yyyy)

Permanent Address

Permanent City

Permanent State Permanent Zip

Home Telephone # (000-000-0000)

Cellular Telephone # (000-000-0000)

E-mail Address

Guardian Name(s)

Guardian E-mail Address

Guardian Work Telephone # (000-000-0000)

Guardian Cellular Telephone # (000-000-0000)

High School Name

Years In Program Graduation Year

Education Plan

Other Education Plan (specify)

Highest Education Goal

College Plan to Attend
1st Choice NC College?
2nd Choice NC College?
3rd Choice NC College?

College Field Plan to Major in

Other Field Plan to Major (specify)

Primary Career Interest

Other Primary Career Interest (specify)

Type of Scholarships and Amount

College Accepted to Attend

NC College?

College Major

Other College Major (specify)

SAT Test Scores
(SAT Writing Test Scores SAT Mathematics Test Scores SAT Critical Reading Test Scores )

ACT Test Scores
(ACT English Test Scores ACT Mathematics Test Scores ACT Reading Test Scores
ACT Science Test Scores ACT Writing Test Scores )

GPA Weighted (0.00) GPA Unweighted (0.00)

PSAT Test Scores

Class Rank (0/00)

Class Rank % Other % (specify)

To what extent have the following people encuraged you (student)to
pursue a career in a math- or scienc-related filed?

Encouragement from Mother or Female Guardian
Encouragement from Father or Male Guardian
Encouragement from Other Relative
Encouragement from Friends or Acquaintances
Encouragement from Guidance Counselor
Encouragement from Pre-College Program Teacher or Advisor
Encouragement from Other Math Teacher
Encouragement from Other Science Teacher
Encouragement from Techer in Other Subject
Encouragement from School Administrator

Are you interested in volunteering to assist other Pre-College Program
students as a tutor, role-model speaker or mentor?


(Do NOT submit survey on-line. Please print out the completed survey and mail it to either your coordinator or the Network Office if instructed by your coordinator. Due date is July 31st.