STUDENT MEMBERSHIP APPLICATION

SECTION A – Student Information
First	Middle	Last		Age
Current Date / /	Student’s birth date / /		Male {_} Female {_}
School	Grade		Race/Ethnicity

PARENTS OR GUARDIANS (TO WHOM CORRESPONDENCE WILL BE SENT)

First name Last name
Relationship to Student
Address
City	State	Zip Code
Home Phone # Parent’s contact #
E-mail Address
Employer’s Name (Optional)
Emergency contact name __________________________________________ Emergency Phone # _____________________________________________

SECTION B - JETS (Junior Engineers Tomorrow’s Scientists) Program

Please rank which JETS class you are interested in attending, with number one (1) being your first choice. You may be placed in a different class than your first choice if that class if filled or you do not meet the course pre-requisites

___ Architecture ___ BASIC Programming ___ C Programming

___ Civil Engineering ___ Electronics ___ Introduction to Internet

___ Mechanical Engineering

Have you attended the JETS program before? _Yes _No How many years ____________

List all JETS classes you have previously attended.

Do you participate in ROTC or have an interest in attending a Service Academy? _ Yes _ No

Do you participate in sports or other extra curricular activities? ______Yes ______ No

If yes, please list all other activities you participate in.

How did you find out about CABPES?

SECTION C - MEP (Math Enrichment Program)

Indicate the course(s) in which you will need assistance. You may choose more than one.

______ Algebra _____ Chemistry ______ Calculus ______ Physics

______ Pre-Algebra _____ Trigonometry ______ Probability & Statistics

______ Geometry ______ Science or Other Please Specify __________________________

List the name of the Math/Science book(s) or workbook you currently use at school.

______________________________________________________________________________

Are you allowed to bring your Math/Science textbook home? _____ Yes _____ No

Math/Science teacher or counselor’s name: ______________________________________

What is your current grade in Math/Science? ___ A ___ B ___ C ___ D ___ F

Have you attended the CABPES’ (MEP) Math Enrichment Program before? __ Yes __ No

Year(s) attended. _________

Are you currently participating in another tutoring program? _____ Yes ____ No

If yes, please list name and day(s) you participate in the program

_______________________________________________________________________________________

_______________________________________________________________________________________

SECTION–D SAT (Scholastic Aptitude Test) Preparation Program

Please select which SAT session you are interested in attending.

______ Fall Session _____ Spring Session

(Classes begin September 29, 2004) (Classes begin February 16, 2005)

Have you previously taken the SAT or ACT test? ____ Yes ____ No

If yes, please provide your test scores __________________________________

What is your career interest? ____________________________________________________________

______________________________________________________________________________________

Have you made plans to attend college? _____ Yes _____ No

List three potential colleges you are interested in attending

1) _______________________________ 2) ________________________ 3) _________________________

Notes: Please notify CABPES of any address or telephone number changes.

Office Use

7/19/2006 11:13 AM