PREP

1. MSEN, CB#3345, UNC-CHAPEL HILL, NC 27599-3345, 919 966-3256 PRE-COLLEGE RESEARCH EXPERIENCES PROGRAM PREP PREP APPLICATION FORM (Please type, or write legibly) Student Profile Male Female Name Last First M.I. Home/Mailing Address County State Zip Telephone (include area code) Parent or Guardian Date of Birth School Name Address City State Zip Current GPA: Telephone (include area code) Grade Level for the school year 2000-2001 (please circle): 11th Grade 12th Grade Are you currently a MSEN Pre-College Student (please circle):Yes No Please circle the science classes that you have completed: Biology Chemistry Physics Other Science Courses: Please circle the math classes that you have completed: Algebra I Algebra II Geometry Trigonometry Pre-Calculus Calculus Please list any technology classes that you have completed: • The information you provide when answering the following question will maximize opportunities for interactions with peers from different racial/ethnic and geographic backgrounds. • Which of these categories best describes your ethnic/racial status? Please circle one. African American Alaska Native American Indian Asian American Caucasian non-Hispanic Filipino American Hispanic American Pacific Islander Other Eligibility (Circle yes or no for each statement) • I am a resident of North Carolina, and a citizen of the United States. Yes No • I am willing to participate in an interview if chosen as a finalist. Yes No • I am committed to full participation throughout the six weeks of the program, workshops, and follow-up classroom activities. Yes No PREP 2000

2. MSEN, CB#3345, UNC-CHAPEL HILL, NC 27599-3345, 919 966-3256 PRE-COLLEGE RESEARCH EXPERIENCES PROGRAM PREP PREP APPLICATION FORM (Please type, or write legibly) Teacher Profile Male Female Name Last First M.I. Home/Mailing Address County State Zip Telephone (include area code) Spouse Other Home Telephone/Business Work Address City State Zip Telephone (include area code) Subjects that you currently teach (please circle): Grade Level that you currently teach (please circle): 6th 7th 8th 9th 10th 11th 12th Are you currently a MSEN Pre-College Teacher (please circle): Yes No Do you currently teach at a designated MSEN Pre-College School (please circle): Yes No • The information you provide when answering the following question will maximize opportunities for interactions with peers from different racial/ethnic and geographic backgrounds. • Which of these categories best describes your ethnic/racial status? Please circle one. African American Alaska Native American Indian Asian American Caucasian non-Hispanic Filipino American Hispanic American Pacific Islander Other Eligibility (Circle yes or no for each statement) • I am a resident of North Carolina, and a citizen of the United States. Yes No • I am willing to participate in an interview if chosen as a finalist. Yes No • I am committed to full participation throughout the six weeks of the program, workshops, and follow-up classroom activities. Yes No PREP 2000