Scholars Program Application
All information you provide is kept confidential.
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First Name *
Middle Name *
Last Name *
Date of Birth *
MM
/
DD
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Phone Number *
Current Address *
City *
State *
Zip Code *
High School you attend? *
What school district are you in? *
Gender
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Age *
Grade Level *
Email *
Ethnic Background *
Citizenship Status *
Have you ever had any disciplinary issues in or out of school? If so, please explain. *
School Club/Organizations *
Sports *
High School Classes *
Required
Select Your Endorsement(s) *
Required
Academic Aspirations *
Required
Employment *
What is your most recent math grade? *
What is your most recent science grade? *
What is your most recent social studies and/or history grade? *
What is your most recent English grade? *
What are your top 3 career interest? *
What are your top 3 college choices? *
Guardian relationship to Applicant *
Guardian Name *
Guardian Address *
City, State, Zip Code
Guardian Phone Number *
Guardian Email *
Does your mother or father have a post secondary degree (Bachelors or higher)? *
Does the student qualify for free or reduced lunch? *
What is the primary language spoken at home? *
Primary Method of Contact *
I consent to have my son’s/daughter’s Middle and/or High School release academic information including, but not limited to transcripts and test scores to the STEM BRIDGES Houston Scholars Program staff. person or persons signing below also authorize the STEM BRIDGES Houston Scholars Program. The representative and/or the news media to photograph, videotape, audiotape, duplicate and transfer to any present or future technology their images while they are scholars or feature subjects in the STEM BRIDGES Houston Scholars Program, its authorized agents, and news media may use the photographs, videotapes, and audio tapes as appropriate to promote STEM BRIDGES Houston and related objectives. No compensation will be paid for this use.                                                                               Do you understand?
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I certify that the information reported on this application is true, complete, and accurate to the best of my knowledge. Falsifying or omitting requested information can delay application or may result is disqualification of eligibility. *
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