Pathways to STEM Application

Pathways to STEM Application

Pathways to STEM is a collaboration between Cal Poly Pomona, the Oak Crest Institute of Science, and the Jet Propulsion Laboratory to engage students in STEM exploration.

Participants will have on- and off-campus experiences that include mentoring, networking, career clarification, and the development of workplace knowledge and skills. Through participation, students will also grow their scientific literacy and science communication skills.

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CONTACT INFORMATION

First and Last Name*

Student ID*

Student Email*

Personal Email*

Cell*

Phone

Permanent Phone number*

Phone

Emergency Contact*

Name/Relationship to you/Phone Number

ACADEMIC INFORMATION

High School*

Citrus Major*

Citrus GPA*

Are you receiving financial aid?*

Yes

Expected Transfer Date*

DEMOGRAPHIC INFORMATION

Date of birth*

Gender*

Select or enter value

Citizenship*

Select or enter value

If you selected Permanent Resident, enter PR ID#:*

Parent/Guardian #1 - Select highest level of education completed*

Select or enter value

Parent/Guardian #2 - Select highest level of education completed*

Select or enter value

Do you identify as Hispanic/Latinx?*

Yes

Racial-Ethnic Background (Check all that apply)*

American Indian or Alaska Native - A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment

Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, & Vietnam

Black or African American - A person having origins in any of the Black racial groups of Africa

Native Hawaiian or Other Pacific Islander -A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands

White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa

Are you currently a member or a veteran of the armed forces?*

Yes

If so, which branch?*

Are you currently working?*

Yes

If so, how many hours per week do you work?*

Do you receive accommodations through DSP&S?*

Yes

Do you have any prior or current health issues (e.g. diabetes, fainting, seizures, and depression)?*

Yes

Do you know how to swim?*

Yes

Have you ever been convicted of a crime other than minor traffic violations, including Nolo Contendere Plea (a plea of no contest)? This does not automatically disqualify you from program participation.*

Yes

PLEASE ANSWER THE FOLLOWING QUESTIONS

Describe your educational goals and your scientific interests. Why did you choose a STEM (science, technology, engineering, and math) major?*

The Pathways to STEM project offers experiential learning and mentoring. How do you think this will benefit you? Include your reasons for wanting to participate in the program.*

If selected, you will collaborate and travel with a group during the project year. What qualities and/or personal characteristics will you bring to this group?*

Submit the following files:*

• Unofficial transcripts from all colleges you have attended

• Copy of your most recent Financial Aid Award

• Copy of your driver's license, or other official ID

Drag and drop files here or

Please read the following statements and check the box below*

• I understand that Pathways to STEM is offered in collaboration with partner institutions. I give my permission for this application to be shared with partner sites to assist with selection.

• I understand that Pathways to STEM has an evaluation component. I give my permission for the documents submitted as part of this application to be utilized for evaluation.

• I hereby certify to the best of my knowledge that all information submitted as a part of this application is complete and correct. I understand that failure to disclose accurate information is grounds for immediate termination from this program.

• I understand Pathways to STEM requires a one‐year commitment and requires off‐campus activities.

Date of application*

Send me a copy of my responses

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