Numass Form – Fill Out and Use This PDF

Department of Physics	Telephone: (404) 215 - 2615
830 Westview Drive	E-mail: kijohnso@morehouse.edu
Dansby Hall 114
Atlanta, GA 30314-1773

NUCLEAR, MATERIAL, AND SPACE SCIENCES

(NuMaSS) SUMMER PROGRAM APPLICATION

Name: ____________________________________________________________________________________

Address: __________________________________________________________________________________

City: ___________________________________ State: ___ Zip Code: ___________________________

Telephone: __________________ Date of Birth: _______ Age: ____ E-mail address: ____________________

Sex:	Female	Male		Social Security Number: _______________________________________
U.S. Citizen:		Yes	No	Alien Registration Number: ____________________________________
Ethnic Origin:		American Indian / Alaskan Native			Asian/Pacific Islander	Hispanic
		Black (Non-Hispanic)			White (Non-Hispanic)	____________
Current Grade Level: _____			Current School: __________________________________			G.P.A: __________

Please complete the following information:

Math Courses Completed:

Math Courses Planned for Next Year:

Science Courses Completed:

Science Courses Planned for Next Year:

Do you have a disability (physical, emotional, learning)? Yes No

If yes, please describe: _______________________________________________________________________

I certify that all information provided on this page is accurate. I understand that falsifying information will result in immediate rejection of your application.

Student Signature: ___________________________________________	Date: ___________________
Parent Signature: ____________________________________________	Date: ___________________

STUDENT PROFILE

Each applicant is asked to express his/her own ideas on this section of the application without assistance

from anyone, including parents, teachers, siblings, etc.

1.Why do you want to participate in the NuMaSS Summer Program? What do you expect to learn or gain from your participation and what will you contribute?

2. What are your plans following graduation from high school? What careers are you interested in pursuing?

3.In your opinion, what is the most significant mathematical or scientific development that affects everyday living? (Please defend your perspective.)

4. What are your favorite and least favorite courses at school and why?

5. What is your major strength and what weaknesses would you like assistance with?

PARENTAL INFORMATION

MOTHER:

Name:______________________________________________________________________________

Occupation: ___________________________________	Employer: ________________________________
Business Phone: ________________________________	Email: ___________________________________

FATHER:

Name:______________________________________________________________________________

Occupation: ___________________________________	Employer: ________________________________
Business Phone: ________________________________	Email: ___________________________________

E M E R G E NCY CONTACT INFORMATION

Name: ______________________________________________ Relationship: __________________________

Home Number: __________________________________ Cell Number: _____________________________

PRIVACY ACT

I understand that the information concerning me, my spouse, and child as client will be kept in confidence and will not be revealed to anyone except NuMaSS Summer Program personnel in accordance with the Family Educational Rights and Privacy Acts.

AUTHORIZATION FOR ACADEMIC RECORDS

I authorize Morehouse College NuMaSS Summer Program to obtain copies of my son’s and/or daughter’s transcript and test scores. I permit NuMaSS Summer Program Staff to release confidential information to postsecondary institutions for educational planning purposes.

I certify that all information provided on this page is accurate. I understand that falsifying information will result in immediate rejection of your application.

Parent(s) Signature(s): _______________________________________________________________________

Student Signature: __________________________________________________________________________

RECOMMENDER INFORMATION

Each student must submit two recommendation forms. One of the forms must be submitted by a current teacher in the Sciences or Mathematics. Provide the information below for the individuals who will be submitting your recommendation forms. Once your application is received, a notification will be sent to these individuals to complete a recommendation form. Ask permission from your teacher or the person you are requesting the recommendation form before putting their name on the application. Each recommender should complete the following information. Please confirm with

your recommender that the recommendation letter has been submitted.

1)

Name ___________________________________________________________________________________________

Email ______________________________________________________________

Phone (Area Code/Number) ____________________________________________________________

Signature ________________________________________________________________________Date __________________

2)

Name ___________________________________________________________________________________________

Email ______________________________________________________________

Phone (Area Code/Number) ____________________________________________________________

Signature ________________________________________________________________________Date __________________

Complete applications must be mailed and receive no later than April 1, 2013 5:oo pm

A complete application include

1.applicant information forms,

2.recommendation survey (to be emailed to the recommender addresses listed above and

3.an official academic transcript sealed from your student’s school.