NYC PREP -- Registration

Applicant Information

First Name:	Last Name:
Date Of Birth: format (mm/dd/yyyy)
Gender: Female Male
Address:
City:	State:	Zip Code:
E-mail:	Ethnicity:

Parent or Guardian Information

Parent Guardian
First Name:	Last Name:
Check this box if the parent/guardian address is the same as the student's
Address:
City:	State:	Zip Code:

Work Phone:	Home Phone:	E-mail:

Household Information

Household Income (Yearly):
$

Household Member:

Education History

Current Grade: 6 7 8 9 10 11 12
Overall Average:	Math Average:	Science Average:
High School Name:
School Type: Public Private	School Region No.:
Address:
City:	State:	Zip Code:
School Phone Number :

Counselor Name:	Counselor Phone:	Counselor E-mail:
Check all of the following subjects you have completed or are currently taking:
Math A	Math B	Sequencial Math I
Sequencial Math II	Sequencial Math III	Geometry
Pre-Calculus	Calculus	Living Environment
Chemistry	Physics	Earth Science
AP Biology	AP Chemistry	AP Calculus
AP Physics
Any regent(s) Exam(s):
Math A Score:	Math B Score:	Sequencial Math I Score:
Sequencial Math II Score:	Sequencial Math III Score:	Living Environment Score:
Physics Score:	Chemistry Score:	Earth Science Score:
SAT score :
Average Math:	Average Verbal :	Average Written :

Write a 100 to 200 words essay below on why you want to attend NASA/STEP Poyecto Access Program. Also, briefly describe any awards or honors received for participation in math and science activities.

References (Math and Science Teachers are required. Other, can be anyone in school, church or community)

Refence 1: Math Science Other
Name:	Phone:	E-mail:

Refence 2: Math Science Other
Name:	Phone:	E-mail:

Applicant Information

Parent or Guardian Information

Household Information

Education History

References (Math and Science Teachers are required. Other, can be anyone in school, church or community)

Which program are you applying for?