Last Name

First Name Middle Initial

Gender Male Female

Ethnicity Africian American American Indian Asian or Pacific Islander Bi or Multi-Racial Caucasian Hispanic Other

PCP Site ECSU FSU NCSU UNCC UNCCH WSSU

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 0 1 2 3 4 5 6 7 Graduation Year

Education Plan Work full-time, never attend college Work full-time, attend college in the future Attend college part-time, work part-time Attend college part-time, work full-time Attend college full-time, not work Attend college full-time, work part-time Attend college full-time, work full-time Do not plan to work or attend college Join the Armed Forces Other (specify)

Other Education Plan (specify)

Highest Education Goal Graduate from high school Graduate from a trade, technical, or business school Complete Armed Forces training Graduate from a 2-year community or junior college Graduate from a 4-year college university Earn a Master's Degree Earn a M.D. Degree Earn a Doctor of Veterinary Medicine Degree Earn a Doctor of Dental Science Degree Earn a Ed.D. or Ph.D. Degree

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

College Field Plan to Major in Mathematics Science Technology Education Engineering Business Law Undecided Not going to college Other (specify)

Other Field Plan to Major (specify)

Primary Career Interest Mathematics Science Technology Education Engineering Business Law Undecided Other (specify)

Other Primary Career Interest (specify)

Scholarships?
Type of Scholarships and Amount

College Accepted to Attend

NC College?

College Major Mathematics Science Technology Education Engineering Business Law Undecided Not going to college Other (specify)

Other College Major (specify)

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

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

GPA Weighted (0.00) GPA Unweighted (0.00)

PSAT Test Scores

Class Rank (0/00)

Class Rank % Top 1% Top 5% Top 10% Top 15% Top 20% Top 25% Other (specify) 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 Not at all Some Very much
Encouragement from Father or Male Guardian Not at all Some Very much
Encouragement from Other Relative Not at all Some Very much
Encouragement from Friends or Acquaintances Not at all Some Very much
Encouragement from Guidance Counselor Not at all Some Very much
Encouragement from Pre-College Program Teacher or Advisor Not at all Some Very much
Encouragement from Other Math Teacher Not at all Some Very much
Encouragement from Other Science Teacher Not at all Some Very much
Encouragement from Techer in Other Subject Not at all Some Very much
Encouragement from School Administrator Not at all Some Very much

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

(Do NOT submit on-line. Please print and mail the completed form to Felicia Umstead
on or before June 10th.)