Stepping Stones to Your Future, Application, University of Maryland, Application

Stepping Stones to Your Future
Stepping Stones 2010

SSTYF Application Part I: Biographical Information

Last Name:	First Name:	MI:
Home Address:
City:	State:	Zip:
Phone:	Birthdate:

Current Grade Level:

Gender:
Male Female

Have you participated in this program before?

Race/Ethnicity: (for statistical purposes only) Please check all that apply

	Asian American/Pacific Islander/Asian		Latino/a
	African American/Black		Multiracial/Multiethnic
	Caucasian/White		Other (Please specify)
	American Indian/Alaskan Native

Name of School:

School Address:		School City:
School State:		School Zip:
School Phone:		School Fax:

Which week do you prefer to attend?

How did you find out about this program?

	School Counselor		Science/Math Teacher
	Internet		Summer Program Fair
	Past Participant		Other WIE Program
			Other (please specify):

Parent/Guardian Information
Parent/Guardian Name:		Home Phone :
Daytime Phone:
Hours that I’m reachable at the Daytime Phone:
* Email Address:		* Please provide an e-mail address that you check frequently. We will be sending you regular updates and announcements regarding your application.

By checking this box, I confirm that the information included is accurate to the best of my
knowledge and that my parent/legal guardian is aware that I am applying for this program.

Note: Please be assured that your information is secure. When you click
submit, you may get a security warning popup. This is because you are being
redirected to the "Thank You" page that is not on the secure server. Just click
"OK" or "continue anyway" to continue.