CSULA LSAMP REGISTRATION FORM



California State University, Los Angeles

5151 State University Drive

Department of Biological Sciences

CSULA-LSAMP

ASCB – Room 323A

323-343-2095 or lsamp@calstatela.edu

Dear New Applicant to LSAMP:

The major objectives of the Louis Stokes Alliance for Minority Participation [LSAMP] program are to increase the numbers of students who graduate in a timely fashion in a SEM (science, engineering or mathematics) discipline and to increase the numbers of students who go on to pursue research careers by pursuing SEM graduate studies.

Attached with this letter is the NEW LSAMP Student application form for students who have never previously filed a new application with LSAMP. You have until September 23, 2013, to submit the TYPED and COMPLETED materials on the attached application form including the required signatures (do NOT leave any questions blank and follow all instructions). Here are some important things to be aware of:

• One of the staff will take a digital head shot at the time you submit your application (your application is considered incomplete without this photo; photos will be used for recognizing your achievements and if you are graduating this year to recognize that achievement)

• If you fail to submit this new application form correctly and completely by September 23, 2013 (which includes the digital photo), your application will be rejected for Fall Quarter 2013.

• Applications that are not typed will not be accepted and this includes following all instructions (particularly for the academic plan – use the proper abbreviations as instructed on the top of the academic plan; obtain the appropriate signatures on the plan as indicated in both the checklist and top of the academic plan; please note: that if you are a Biology or Microbiology major, Dr. Jefferson can approve your plan if it is done correctly according to prior advisement; if you are in the MEP program, MEP staff may approve your plan if it is done correctly and you have met with an academic advisor). Please make sure that you speak to an academic advisor BEFORE you complete your plan. Most SEM courses have prerequisites and courses must be taken in specific order to successfully complete the course on your first attempt.

• During the academic year, you will receive the LSAMP REPORT FORM. You must complete and submit it by the indicated deadline.

• We will examine your submitted LSAMP REPORT FORM, your level of participation in research or other LSAMP activities, your academic progress and your overall academic performance to determine whether or not you are eligible for other specific program incentives including priority registration.

• As we receive information, we will continue to send you emails about various opportunities in the LA area, throughout California, the USA, as well as various global opportunities.

• We have many opportunities to provide funding to students to attend professional conferences, visit graduate schools, GRE preparation, and to learn about summer internships (note that deadlines for summer internships are often in winter or early spring quarters.)

• Visit the LSAMP website for more information:

If you have any questions about your application, contact us by email (lsamp@calstatela.edu) or by phone (323/343-2095). If you call us, please speak slowly and clearly leaving a message with your name and phone number for us to call you back. IF YOUR ADDRESS, PHONE NUMBER, E-MAIL ADDRESS, OR NAME, ETC., CHANGES, PLEASE INFORM THE LSAMP OFFICE AS SOON AS POSSIBLE.

CSU, Los Angeles

Louis Stokes Alliance for Minority Participation Program

LSAMP NEW APPLICANT INFORMATION

DEADLINE TO APPLY FOR 2013-2014 = September 23, 2013 (NEW Participants)

You will only have to complete this application once while you are a student at CSULA so do it very carefully. Incomplete applications will not be accepted. Use check list below and make sure you answer ALL questions! You may bring all of these completed items to the LSAMP office (ASCB - Room 323A). Or if you prefer, you may mail all of the completed materials to the following address (be sure to include everything indicated below):

LSAMP Office – ASCB - Room 323A

CSULA c/o M. Jefferson

5151 State University Drive

Los Angeles, CA 90032-8201

LSAMP UNDERGRADUATE ELIGIBILITY CRITERIA

Must be US citizen or permanent resident

Must have a declared science (biochemistry, biology, chemistry, exercise science, geology, microbiology, natural science, physics), engineering (civil, computer science, electrical, mechanical, other), or mathematics (math) (SEM) major in GET

Must be working on first bachelor’s degree at CSU, Los Angeles

Must be enrolled at CSULA each AY quarter (excluding summer)

Must have demonstrated that you have faced specific educational, social or economic barriers in your pursuit of higher education

Academic progress must be demonstrated each year by completion of requirements for major degree program and progress toward graduation

Application must be complete with all components clearly readable (typed applications REQUIRED)

CUM GPA = 2.000 or higher to qualify for any program funding and priority registration

Active participation in program activities and completion of the LSAMP Report Form to qualify for any program funding and priority registration

Demonstrated interest in a research career or graduate school to qualify for specific program funding

LSAMP CHECKLIST FOR COMPLETE APPLICATION

_____ Every question must be answered. (Note: your application is considered incomplete if any question is left blank. Read questions carefully to avoid having your application rejected for inappropriate responses.)

_____ Information you provided is accurate according to GET.

_____ I understand that to fill in the specific checkboxes to many of the questions, I simply have to double click on the boxes and chose a fill-in color.

_____ If Permanent Resident, you must include a copy of both sides of your PR card with your photo on it.

_____ All applications must include a printout of your Academic Year 13-14 and Financial Aid Summary 13-14 forms (see page 7 of this application for precise instructions on what each of these forms are and how to obtain them.)

_____ Properly completed Academic Plan with required signatures (read and follow all instructions on top of 8).

_____ Academic Plan (p. 8) is signed by a major department faculty academic advisor or MEP advisor if engineering or computer science major (plan ahead – application is unacceptable without faculty signature).

_____ Signed and dated Statement of Understanding (see p. 9)

_____ Arrange to have your digital photo taken by LSAMP Office Staff (Go to ASCB-323A or call 323/343-2095).

KEEP PAGES 1 & 2 FOR YOUR OWN RECORDS. SUBMIT ONLY APPLICATION (PAGES 3-9).

CSULA LSAMP UNDERGRADUATE APPLICATION FORM

Please type information in right column

|1) |First Name: | |

|2) |Middle Initial (type none if no M.I.) | |

|3) |Last Name: | |

|4) |CIN (without dashes): | |

|5) |SSN with dashes (required for program incentives): | |

|6) |Date of Birth (format = mm/dd/yyyy): | |

|7) |Street Address (if you live in student housing make | |

| |sure you include both your current address and | |

| |permanent address): | |

|8) |Apartment # (type none, if none): | |

|9) |City: | |

|10) |State: | |

|11) |Zip Code: | |

|12) |Home phone # (e.g., 555-555-555): | |

|13) |Cell phone # (type none if none): | |

|14) |CSULA Email address (type userid): | @calstatela.edu |

|15) |Personal Email address (type none if none): | |

|16) |Citizenship (if permanent resident, must provide a copy| US citizen |

| |of PR photo id and type PR # in box provided): | |

| | |Permanent Resident (PR) #: |

|17) |Gender: | Male Female |

|18) |Ethnicity: | Hispanic or Latino/a Not Hispanic or Latino/a |

|19) |Race (list provided by National Science Foundation; | Black or African American Asian |

| |check as many that apply; if you check other, explain):| |

| | |Native American Indian Alaska Native |

| | | |

| | |Native Hawaiian White |

| | | |

| | |Other Pacific Islander Hispanic/Latino/a |

| | | |

| | |Other |

|20) |Disabilities (if you check other, explain) | NONE |

| | | |

| | |Hearing Impairment |

| | | |

| | |Visual Impairment |

| | | |

| | |Mobility/Orthopedic Impairment |

| | | |

| | |Other |

|21) |First Quarter and Year you enrolled in classes at | |

| |CSULA: | |

|22) |Quarter & Year you plan or hope to graduate in your | |

| |major from CSULA: | |

|23) |Did you transfer to CSULA from another | Yes (Indicate the name of school you transferred from) |

| |college/university? |No |

|24) |Class Level (Use your GET access to verify class level | First-time Freshman (0 college units earned) |

| |is correct online): | |

| | |Freshman (1 - 44 college units earned) |

| | | |

| | |Sophomore (45 - 89 college units earned) |

| | | |

| | |Junior (90 – 134 college units earned) |

| | | |

| | |Senior (135 or more college units earned) |

|25) |Major (Use your GET access to verify your major is | Biochemistry (BIOC) |

| |correct online; submit a change of major form to ADM | |

| |146 if information is incorrect; proper abbreviation |Biology (BIOL) |

| |for major is provided; if declared DUAL major, check | |

| |one(s) that apply and use other, if one of the dual |Chemistry (CHEM) |

| |majors is non-SEM; note that one of the dual majors | |

| |must be indicated in the right column to be eligible |Civil Engineering (CE) |

| |for program; if you do not verify that your major is | |

| |correct in GET, your application will be rejected if |Computer Science (CS) |

| |the major is different than what you checked here) | |

| | |Electrical Engineering (EE) |

| | | |

| | |Exercise Science (EXER) |

| | | |

| | |Geology (GEOL) |

| | | |

| | |Mathematics (MATH) |

| | | |

| | |Mechanical Engineering (ME) |

| | | |

| | |Microbiology (MICR) |

| | | |

| | |Natural Science (NATS) |

| | | |

| | |Physics (PHYS) |

| | | |

| | |Other Engineering (ENGR) |

| | | |

| | |Other: |

|26) |Have you completed all lower division MATH requirements| Yes |

| |(100 and 200-level courses) required for your major? | |

| | |No |

|27) |Have you completed all lower division ENGNEERING or | Yes |

| |SCIENCE requirements (100 and 200-level courses) | |

| |required for your major? |No |

|28) |Are you a new transfer student starting in Summer or | Yes |

| |Fall Quarter 2013? | |

| | |No |

|29) |Are you eligible to receive financial aid? | Yes |

| | | |

| | |No |

|30) |Are you receiving financial aid for current year? | Yes |

| | | |

| | |No |

|31) |If you are eligible to receive financial aid but not | Yes |

| |receiving it, explain why. Otherwise type N/A in right | |

| |column box. |No |

|32) |If you are NOT eligible to receive financial aid, | Yes |

| |explain why. Otherwise type N/A in right column box. | |

| | |No |

|33) |What is your career goal? That is, what do you want to | |

| |do after you receive your bachelor’s degree in science,| |

| |engineering or math? | |

|34) |Very briefly describe any opportunities you have had to| |

| |do research. If none, type none in right column. | |

|35) |If your answer to question 34 was none, please explain | |

| |why – (e.g., have you not pursued or investigated such | |

| |opportunities or have you no interest in research or | |

| |have you been too busy to explore opportunities or some| |

| |other reason). If you have briefly described research | |

| |that you have participated in for Q34, type N/A in | |

| |right column. | |

|36) |Very briefly describe any internship opportunities you | |

| |have had. If none, type none in right column. | |

|37) |If your answer to question 36 was none, please explain | |

| |why – have you not pursued or investigated such | |

| |opportunities or have you no interest in doing | |

| |internships or have you been too busy to explore | |

| |opportunities or is it too early in your major to do an| |

| |internship. If you have briefly described internships | |

| |that you have participated in for Q36, type N/A in | |

| |right column. | |

|38) |Are you interested in obtaining a Masters degree? | Yes Maybe |

| | | |

| | |No |

|39) |Are you interested in obtaining the PhD? | Yes Maybe |

| | | |

| | |No |

|40) |How many hours do you work per week in a typical month?| 0 hours, I do NOT work. |

| | | |

| | |1-10 hours per week |

| | | |

| | |11-20 hours per week |

| | | |

| | |21-30 hours per week |

| | | |

| | |31-40 hours per week |

| | | |

| | |more than 40 hours per week |

|41) |If you work, do you work on or off campus? | I do NOT work. |

| | | |

| | |work on campus work off campus |

|42) |Are you interested in attending Summer Internship | Yes Maybe |

| |Opportunities Program at CSU, Sacramento in early | |

| |December? |No |

|43) |Are you interested in attending the Graduate School | Yes Maybe |

| |Diversity Day Program in November or April? | |

| | |No |

|44) | | |

| |Summarize the specific educational, social or economic | |

| |barriers you have faced in your pursuit of higher | |

| |education. Failure to respond to this or any other | |

| |question on the application form will result in | |

| |rejection of your application. Speaking a language | |

| |other than English is not considered an educational, | |

| |social or economic barrier. | |

|45) | | |

| |Describe how your participation in CSU- LSAMP | |

| |Undergraduate Program will contribute to the program’s | |

| |goals as well as the goals of the National Science | |

| |Foundation (NSF) of broadening participation by others | |

| |who may not be as well represented in specific science,| |

| |engineering, and mathematics (SEM) disciplines. | |

|46) |Are you interested in participating in research | Yes Maybe |

| |training courses to learn about research careers and | |

| |what research is all about? |No |

|47) |Are you interested in applying in March or April for | Yes Maybe |

| |the CSU LSAMP Scholars Program, which is for students | |

| |who are interested in pursuing graduate studies, |No |

| |particularly the PhD, (must have only one year of | |

| |undergraduate work remaining)? A separate application | |

| |form available in March is required, and up to $1000 | |

| |may be awarded for the following academic year. | |

|48) |What science, engineering or mathematics-related | |

| |student clubs are you a member of? If none, type none | |

| |in the right column. | |

|49) |Are you interested in presenting research at a | Yes Maybe |

| |professional meeting in either oral or poster format in| |

| |2013-14? |No |

|50) |Are you interested in visiting graduate schools in | Yes Maybe |

| |2013-14? | |

| | |No |

Please note that it is your responsibility to notify us immediately, if any of this information changes.

FINANCIAL AID INFORMATION

Important – Read this page carefully even if you do NOT receive financial aid.

A. Regardless of whether or not you are receiving financial aid from CSULA, all applicants must PRINT from your GET access the following TWO forms by following these instructions:

1. Use the GET Website () to obtain the following two forms:

Academic Year 13-14 form

Financial Aid Summary 13-14 form

2. Log into your GET account.

3. Go to the Student Services Home Link.

4. Go to FINANCES Link.

5. Look under FINANCIAL AID & click on VIEW MY FINANCIAL AID Link.

6. Select the appropriate year you want to look under.

7. Now you will be viewing the FINANCIAL AID SUMMARY 13-14. We refer to this page as the Academic Year 13-14 because it shows everything that you are eligible to receive in 2013-2014 by each quarter (PRINT THIS PAGE).

8. Next scroll down near bottom of that same page and click on FINANCIAL AID SUMMARY 13-14.

9. Now you will be viewing your FINANCIAL AID SUMMARY 13-14, which shows your UNMET NEED for both AY13-14 and SU13 (PRINT THIS PAGE).

10. Submit the two pages that you just printed out to the LSAMP office (ASC-Wing B, Room 323A) with the rest of your application.

B. If you are receiving financial aid from CSULA, and if you have no unmet need but have loans that you have accepted as part of your financial aid packet, any funds that you may receive from this program may result in a reduction in your loans received from Financial Aid. Remember, loans must be paid back and receiving awards from this program will result in less money you will have to pay back (as long as the information that you provided is accurate and approved by the Office of Financial Aid).

C. If you are receiving financial aid from CSULA, and if you have no unmet need and no loans as part of your financial aid package, we MAY NOT be able to provide you with any stipend for which you may be eligible. The Financial Aid Office determines whether or not you are eligible for a stipend– LSAMP does NOT control this decision. If you fall into this category, you may be eligible for other incentives.

LSAMP ACADEMIC PLAN FOR CSULA PARTICIPANTS

(Complete this one year plan with an academic advisor listing when you will take specific requirements)

Please sign the form and have a faculty academic advisor also sign the form (see checklist for other specifics on who can sign form). Provide all information requested. Indicate the total units that you will take each quarter. Under the Course # column use the proper department abbreviations (see page 1 of the Schedule of Classes) followed by the course number (For example, CHEM 101; BIOL 100A; ME 401; ENGR 300; CS 260; MICR 300; etc). Under the Units column, specify the number of units that the course is worth. Academic progress is a requirement of LSAMP! *If not enrolled in SUMMER 2013 classes, explain what you will be doing. THIS Page MUST BE TYPED, then printed out, and proper signatures obtained (see checklist on page two)! Failure to follow these instructions will result in rejection of your application.

Student's Name: _______________________ Major: _______________ CIN: __________________

Minor (specify if any or indicate none if no minor): __________________ Date: __________________

|QTR/YR: Summer 2013* |QTR/YR: fall 2013 |

|Course # |Units |Course # |Units |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

|Total Units | |Total Units | |

|QTR/YR: WINTER 2014 |QTR/YR: SPRING 2014 |

|Course # |Units |Course # |Units |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

|Total Units | |Total Units | |

Your Signature: ___________________________ Academic Advisor's Signature: ___________________

Proposed Graduation Quarter & Year: _______ Current CUM GPA (look up in GET): __________________

Passed WPE in ____________________________ Print Name of Faculty Advisor: ___________________

(If not yet taken, state NOT TAKEN on line above)

During the academic year, we will email you a LSAMP REPORT FORM which must be completed to determine possible eligibility for priority registration or stipends. You must submit the LSAMP REPORT FORM by the deadline (which will be indicated on the form). Please note that in order to receive priority registration for a given quarter, you must complete the LSAMP REPORT FORM by the deadline indicated on the form. If you are eligible for a stipend during the 2013-2014 academic year, we will ask you to sign a stipend form and a vendor form. We will also complete a Coordination of Aid (COA) form that must be approved by the Office of Financial Aid. Please note that since stipends are based on your participation, degree progress, and academic performance overall, stipends are not usually awarded until the end of quarter or in many cases at the end of the academic year. The stipend form requires that we include the following information (so complete the appropriate information and be certain to let us know if this information changes during the year).

• _____ I do NOT work on campus.

• _____ I do work on campus in the following position:

▪ Title of your position: ________________________________________

▪ Name of Department: ________________________________________

▪ Hourly compensation: _$__________________per hour_____________

Please read the statements below, print your name, sign where indicated, and date the form:

The information which I have submitted in my CSU-LSAMP Undergraduate Program Application is true and accurate to the best of my knowledge. I understand that to track the progress of CSU-LSAMP participants and to evaluate program effectiveness, CSU-LSAMP requires access to student information. The CSU-LSAMP program is required to report individual student data to the National Science Foundation including social security number, ethnicity, GPA, and enrollment status. This information is also used to study student transfer, retention, progression, and graduation. Photographs and research abstracts may also be obtained for use by the CSU-LSAMP program in program dissemination materials such as websites, newsletters, and reports. The student data are collected by the CSU-LSAMP Statewide Office at California State University, Sacramento and each of the 22 affiliated Alliance CSU campuses.

I authorize release and use of personal information, as described above, to the CSU-LSAMP program. I understand that this information is to be used solely for evaluating the impact and effectiveness of the CSU-LSAMP program and that individual student data will not be released to parties other than those directly involved with the program.

I also understand that when I submit abstracts, research papers, and give poster or oral presentations I must properly acknowledge the CSU-LSAMP grant in the following format at the end of the abstract and on the poster itself: Supported by NSF funds to CSU-LSAMP and Office of the Chancellor funds.

I have read and understand all of the statements above.

Printed Name of Applicant: ___________________________________________________________

Signature of Applicant: ___________________________________________________________

Today’s Date: ___________________________________________________________

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