STEM Starter Academy Pathfinders Application 23-24

The STEM Starter Academy (SSA) appreciates your interest in the Pathfinders program which is available to students majoring in a Science, Engineering, Technology, or Math field. We are gathering the information below to ensure we are prepared to best serve your needs.

PERSONAL INFORMATION

NAME (First, MI, Last)

PREFERRED NAME (If Applicable)

STUDENT ID #

DATE OF BIRTH (MM/DD/YY)

GENDER

PRONOUNS

RACE

ETHNICITY

ADDRESS (Include City/Town & Zip Code)

PRIMARY PHONE NUMBER

Ok to leave voicemail?

ALTERNATIVE PHONE NUMBER

Ok to leave voicemail?

EMAIL ADDRESS

SECONDARY EMAIL ADDRESS

FIRST LANGUAGE

SECOND LANGUAGE (If applicable)

DO YOU HAVE A STUDENT VISA?

MARITAL STATUS

NUMBER OF DEPENDENT CHILDREN

ARE YOU AND/OR YOUR SPOUSE A VETERAN?

EDUCATIONAL & WORK HISTORY

HIGH SCHOOL(s) ATTENDED

WHICH OF THE FOLLOWING DO YOU HAVE?

OTHER COLLEGES/UNIVERSITIES ATTENDED (If applicable - Include years attended)

DEGREES EARNED (If applicable)

WHEN DID YOU FIRST ENROLL AT MIDDLESEX COMMUNITY COLLEGE?

MAJOR

CURRENT GPA (Leave blank if this is your first semester)

HAVE YOU APPLIED FOR FINANCIAL AID?

IF YOU ARE RECEIVING FINANCIAL AID, PLEASE SPECIFY WHAT YOU HAVE BEEN AWARDED

PELL GRANT

LOANS

SCHOLARSHIP

TUITION WAIVER

OTHER

ARE YOU CURRENTLY EMPLOYED OR SELF-EMPLOYED?

IF SO, PLEASE SPECIFY IF YOU'RE WORKING FULL-TIME or PART-TIME

COMPANY AND JOB TITLE

GOALS

EDUCATIONAL GOALS

CAREER GOALS

ANY ADDITIONAL INFORMATION AND/OR CONCERNS YOU'D LIKE TO SHARE WITH US

Required

I CERTIFY THAT ALL INFORMATION IS TRUE TO THE BEST OF MY KNOWLEDGE. I ALSO GIVE PERMISSION FOR SSA STAFF TO HAVE ACCESS TO MY ENROLLMENT AND GRADE INFORMATION AT MIDDLESEX COMMUNITY COLLEGE.

SIGNATURE (Type Name)

DATE (MM/DD/YY)