Esteem Research Mentoring Program Application, University of Maryland

ESTEEM Research Mentoring Program
Application 2009
Deadline: March 30, 2009

Student Data Section

Last Name:		First Name:	MI:
Address:
City:		State:	Zip:
Phone:		Birthday:
*Email:	>>	* Please give us an e-mail address that you check frequently. We will be sending you regular updates and announcements regarding your application.

Gender: (for statistical purposes only) Female Male

Ethnic Group: (for statistical purposes only) Please check all that apply

	African/African American		Latino/Hispanic
	Asian		Caucasian (not Hispanic)
	Native American		Other (Please specify)

Educational Data Section

Name of High School:

High School Address:		School City:
School State:		School Zip:
Current Grade:	(program is only for students who will complete the 11th grade in June 2009)
Guidance Counselor:		Phone:
Overall GPA:	(on a 4.0 scale)

PSAT	SAT
Date taken:	Date taken:
Verbal	Verbal
Math	Math

Transcript: Please mail a copy of your high school transcript for 9th and 10th grades and a copy of your report card 1st, 2nd, and 3rd marking periods for the 11th grade by March 30 to:

ESTEEM Research Mentoring Program
ATTN: Mrs. LaWanda S. Kamalidiin
1131 Martin Hall
College Park, MD 20742

In which area of engineering are you interested?

Aerospace	Electrical & Computer
Bioengineering	Fire Protection
Chemical & Biomolecular	Materials Science
Civil & Environmental	Mechanical

Science/Mathematics/Technology/Engineering Courses Taken

Mathematics Courses	Grade Received	Credit Earned	Indicate if Honors or Advanced Placement (AP)	Grade Level When Taken (9, 10, 11)

Science Courses	Grade Received	Credit Earned	Indicate if Honors or Advanced Placement (AP)	Grade Level When Taken (9, 10, 11)

Computer/Technology Engineering Courses	Grade Received	Credit Earned	Indicate if Honors or Advanced Placement (AP)	Grade Level When Taken (9, 10, 11)

500 Word Essay (no more than 3500 characters)

( You may enter up to 3500 characters. )

characters left

I certify by my submission of the on-line application that all information I have submitted is accurate and any misrepresentation of this information will be cause for my disqualification from consideration for the program. I also understand that if selected to participate in ESTEEM, that I must participate for the full duration of the program in the summer and academic year. Failure to do so will cause my immediate termination of my internship.

REMEMBER: Your application for ESTEEM is not complete until your parent/guardian completes
the on-line parent/guardian data form and the teacher recommendation is received.

Note: Please be assured that your information is secure. When you click submit, you may get a security warning popup. This is because you are being redirected to the "Thank You" page that is not on the secure server. Just click "OK" to continue.