your program title

#name# in Program number-#no#

Your contact Address
          Number   Street
         City
         State            Zip -
School
Age
Grade in School

Background Information

Years at current school
Years of education in the United States
The area in which you live is

Urban
Suburban
Rural
Reservation

Your school is in an area that is

Urban
Suburban
Rural
Reservation

Can you get free lunch at school yes no don't know

Your school is (check all that apply)

Private
Public
Parochial
Magnet
Charter
Home school
Coed
All girls
All boys

Gender and age of your brothers and sisters(if any)

No	Gender	Age
1.
2.
3.
4.
5.

Your ethnicity is

African American
Asian American
European American
Hispanic American
Native American
Other

Language spoken most at home
Other languages spoken at home(write them separated by commas)
Occupation of father
Occupation of mother

Education of father

Completed 6th grade
Completed 8th grade
Completed high school
Attended college
Bachelor's degree
Some graduate school
Master's degree
M.D. degree
Ph. D degree

Education of mother

Completed 6th grade
Completed 8th grade
Completed high school
Attended college
Bachelor's degree
Some graduate school
Master's degree
M.D. degree
Ph. D degree

Academic information

1.Is there a computer at home Yes No

2.If there is a computer at home please fill out the following or skip to 3

Computing @ home

How easy is it for you to get access to it at home

it is mine alone
whenever I want
most of the time
sometimes
not often enough
never

Used for	Daily	3-5 times/ week	1-2 times/ week	2-3 times/ month	Less often	never
Calculating
Writing Papers
Email
Web-browsing for fun
Web-browsing for research/ school work
Playing games

3.Do you have acces to a computer at school Yes No

4.If you do have access to a computer at school please fill out the following or skip to 5

Computing @ school

How easy is it for you to get access to it at school

it is mine alone
whenever I want
most of the time
sometimes
not often enough
never

Used for	Daily	3-5 times/ week	1-2 times/ week	2-3 times/ month	Less often	never
Calculating
Writing Papers
Email
Web-browsing for fun
Web-browsing for research/ school work
Playing games

5.What math/science/computer courses are you taking in school now ? Include courses you
have just completed or completed in summer

Math Courses Science Courses Computer Courses

6.Have you participated in any special math/science/computer programs before?If so, what kind and when ?

No Program Type Focus Year

1.

2.

3.

4.

7.Why did you choose to attend this program

teacher recommendation
parent recommendation
i wanted to
i had no choice

8.What extra-cirricular activities are you involved in?(clubs, sports,jobs,church,music...etc)

No	Extra-cirricular activities
1.
2.
3.
4.
5.
6.

9.How would you rate your interest in Math Science or Engineering Courses
in a scale of ten?
1 2 3 4 5 6 7 8 9 10