Black Male College Explorers Program Application
Questions marked by * are required.
1.
Name: *
2.
Email: *
3.
Home Address:
4.
City/State/Zip:
5.
Home Phone:
6.
Social Security Number (last 4 digits):
7.
Date of Birth (mm/dd/yyyy): *
8.
Age:
9.
Sex:
Female
Male
10.
Ethnic Background:
11.
Person to Contact in Case of Emergency: *
12.
Relation to Student: *
13.
Emergency Contact Phone: *
14.
Emergency Contact Address:
15.
Emergency Contact City/State/Zip:
16.
Emergency Contact E-mail: *
17.
Check area(s) of interest:
Business
Natural Science
Social Science
Mathematics
Education
Art
Aviation
Music
Computer Science
Journalism
18.
Other profession of interest:
19.
List the organizations to which you belong and the honors you have received:
20.
Special Skills/Hobbies:
21.
Please list current courses: *
22.
Current Classification: *
-
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
FRS
23.
Cumulative G.P.A.:
24.
Test Scores:
25.
Discipline Referrals:
26.
Absentees:
27.
Tardiness:
28.
Suspensions:
29.
Incarceration Record:
30.
Current Class Schedule:
31.
Expected Date of Graduation (month and year):
32.
List work or volunteer experiences relevant to your professional interests:
33.
Work or Volunteer Position(s):
34.
Duties/Responsibilities:
35.
Work or Volunteer Date(s):