I. General Information - California State University, Los ...



Everything except “signatures” and “date signed” MUST BE plete sections I through VIII before submission to LSAMP Office (ASC Rosser – 360).Depending on number of applicants received on any given day, it may take a week or slightly longer to review and make a decision as to whether or not your application is accepted or rejected. A digital photo will be taken when you submit the application.One of the Program Coordinators will complete section VIII and then return the application to LSAMP staff.An LSAMP staff member will call you to complete section IX or to inform you that your application was rejected.Make sure all questions and answers remain on the specific page that they currently are on – if necessary reduce the font size of your answer or length of the line after you type the answer. If you need to provide a more lengthy explanation to any specific question than the space provided, add a separate typed page with specific question to which you are responding.In the HEADER region of Page 3 (very top line on page 3), you must type your full name (First Middle Last). To do this, use your mouse to highlight the entire line and then type your name. If you do this, your name is underlined and format is correct. When you are done, close your header and finish the other items on page 3. Your name should now appear on the top of all remaining pages.On Pages 2 through 5 you have two types of questions: those with lines with a gray area (e.g., name) and check box questions (e.g., gender).For all line questions with gray areas, double click your mouse button on the gray area to highlight entire line and then type your answer to the question. For check box questions, determine your answer and use your mouse to double-click on that box. A “check box form field options” panel opens up. Change the default value from “not checked” to “checked” and then press ok. Your choice should now be checked in the appropriate box.Please note that for the Race question, you can check more than one answer if you are multi-racial.The email address listed on page 2 is your PREFERRED email address to which we will send you information about program opportunities and Early Registration.Do not leave anything blank – type “none” or N/A if a question does not apply.To find your MAJOR GPA in GET (which is needed on page 3), in the pull down menu of Student Service Center, select Academic Requirements. It appears at the bottom of your Academic Requirements screen under the header “Major Units/GPA Requirements.” Click on this heading to expand and show your MAJOR GPA.On page 5 – Section V, please follow the instructions in section V carefully and attach the two required documents to your application regardless of whether or not you receive financial aid.On page 6 – Section VI, please follow the instructions in Section VI carefully and attach the correct Academic Plan.Submit all required components of the LSAMP Office (ASC – Rosser – 360) during the posted hours.You may call LSAMP at (323) 343-2095 or email lsamp@calstatela.edu. Remove this page when you submit the application to LSAMP -45720-68897500975360-570865California State University Louis Stokes Alliance for Minority Participation Program (CSU-LSAMP)APPLICATION00California State University Louis Stokes Alliance for Minority Participation Program (CSU-LSAMP)APPLICATIONCAMPUS: Los AngelesYEAR: 2017-2018Initiated in 1993-1994, CSU-LSAMP is an alliance of the 23 campuses of the California State University (CSU) system which supports a coordinated and comprehensive system-wide approach to broadening participation in science, technology, engineering and mathematics (STEM) disciplines.Each of the CSU campuses has a CSU-LSAMP program that offers an array of activities and services designed to improve retention and graduation of undergraduate students in STEM. In addition, CSU-LSAMP seeks to increase the number of CSU-LSAMP students who enter STEM graduate programs. To be eligible to participate in CSU-LSAMP, students must:Be a U.S. Citizen or Permanent Resident.Be enrolled at a participating campus in an undergraduate major in a STEM discipline or have expressed an interest in pursuing a STEM baccalaureate degree.Be an individual who has faced or faces social, educational, or economic barriers to careers in STEM. ?Each CSU-LSAMP campus program may have additional eligibility requirements. Please see the Campus Coordinator.I. General InformationGender: FORMCHECKBOX Male FORMCHECKBOX FemaleName: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Last (Surname)FirstMiddleAddress: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Street CityZip CodeTelephone: ( FORMTEXT ?????) FORMTEXT ?????Email: FORMTEXT ????? Please include area codeDate of Birth: FORMTEXT ????? Place of Birth: FORMTEXT ????? City, State, & CountrySocial Security #: FORMTEXT ????? Citizenship: FORMCHECKBOX U.S. Citizen FORMCHECKBOX Permanent ResidentIf applicable, Permanent Resident Registration #: FORMTEXT ?????Please mark one of the boxes provided for both “Ethnicity” and “Race.” Ethnicity (for statistical purposes only): FORMCHECKBOX Hispanic or Latino (A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race) FORMCHECKBOX Not Hispanic or Latino FORMCHECKBOX Decline to State Race (for statistical purposes only): FORMCHECKBOX Black or African-American - A person having origins in any of the black racial groups in Africa FORMCHECKBOX Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, Polynesia, Micronesia, or other Pacific Islands FORMCHECKBOX American Indian - A person having origins in any of the original peoples of North America and maintaining cultural identification through tribal affiliation or community recognition FORMCHECKBOX Alaska Native - A person having origins in any of the original peoples of Alaska, including Eskimos or Aleuts FORMCHECKBOX Asian - A person having origins in any of the original peoples of East Asia, Southeast Asia, or the Indian subcontinent. This area includes, for example, China, India, Indonesia, Japan, Korea, and Vietnam FORMCHECKBOX White - A person having origins in any of the original peoples of Europe, North Africa, or the Middle East FORMCHECKBOX Other (specify): FORMTEXT ????? FORMCHECKBOX Decline to StateII. Personal InformationPlease indicate your parents’ level of education:Mother: FORMCHECKBOX No College FORMCHECKBOX Some College FORMCHECKBOX College Graduate FORMCHECKBOX Graduate SchoolFather: FORMCHECKBOX No College FORMCHECKBOX Some College FORMCHECKBOX College Graduate FORMCHECKBOX Graduate SchoolDisability Status (again, for statistical purposes only): Please check “yes” if any of the disabilities listed below the check box apply to you. Otherwise, check no or decline to state. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Decline to State Deaf or serious difficulty hearingBlind or serious difficulty seeing even when wearing glassesSerious difficulty walking or climbing stairsOther serious disability related to a physical, mental, or emotional conditionAre you a veteran of the U.S. Armed Forces? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Decline to State As an undergraduate, are you eligible for need-based financial aid? FORMCHECKBOX Yes FORMCHECKBOX NoAre you treated as an independent student for financial aid purposes? FORMCHECKBOX Yes FORMCHECKBOX NoWhat is your Personal yearly income? FORMCHECKBOX Less than $10,000 FORMCHECKBOX $10,001 - $20,000 FORMCHECKBOX $20,001 - $30,000 FORMCHECKBOX More than $30,000What is your Family’s yearly income? FORMCHECKBOX Less than $10,000 FORMCHECKBOX $10,001 - $20,000 FORMCHECKBOX $20,001 - $30,000 FORMCHECKBOX More than $30,000III. Educational InformationMajor: FORMTEXT ????? Minor (if any): FORMTEXT ?????Class Level: FORMTEXT ?????(e.g. freshman, sophomore, junior, senior)Total Number of Units Completed: FORMTEXT ?????_____ FORMCHECKBOX Semester FORMCHECKBOX QuarterTotal Number of Major Units Completed: FORMTEXT ????? FORMCHECKBOX Semester FORMCHECKBOX QuarterGPA (Do not round up – 3 decimal places available in GET): FORMTEXT ????? FORMTEXT ?????Cumulative GPAMajor GPATERM & YEAR you expect to receive your CSU Los Angeles Undergraduate Degree: FORMTEXT ?????_____ Anticipated Undergraduate Degree (Bachelor of Arts-BA or Bachelor of Science-BS): FORMTEXT ?????Did you transfer from a California Community College (2-year school)? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, which college: FORMTEXT ?????If yes, how many units did you complete prior to transferring? FORMTEXT ?????Did you complete an Associate’s degree? FORMCHECKBOX Yes FORMCHECKBOX NoIV. Additional InformationCal State LA CIN: FORMTEXT ?????_____Cal State LA Email address: FORMTEXT ?????_____First TERM and YEAR you enrolled in classes at Cal State LA: FORMTEXT ?????_____Have you completed all lower division MATH requirements (1000 and 2000-level courses) required for your major? FORMCHECKBOX Yes FORMCHECKBOX NoHave you completed all lower division ENGINEERING and/or SCIENCE requirements (1000 and 2000-level courses) required for your major? FORMCHECKBOX Yes FORMCHECKBOX NoAre you eligible to receive financial aid? FORMCHECKBOX Yes FORMCHECKBOX NoAre you receiving financial aid for this academic year? FORMCHECKBOX Yes FORMCHECKBOX NoIf you answered yes to question G and no to question H, please explain why. Otherwise, type N/A: FORMTEXT ?????_What is your career goal (what do you want to do after you graduate)? FORMTEXT ?????_Have you had any opportunities to do research prior to today? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently doing research? FORMCHECKBOX Yes FORMCHECKBOX No; if YES, indicate where: FORMTEXT ?????_Have you had any internship opportunities (paid or unpaid)? FORMCHECKBOX Yes FORMCHECKBOX NoDo you currently have an internship? FORMCHECKBOX Yes FORMCHECKBOX NoAre you interested in obtaining a graduate degree at the Masters level after you graduate? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX MaybeAre you interested in obtaining a graduate degree at the PhD level after you graduate? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX MaybeAre you interested in teaching at any educational level? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX MaybeAre you interested in obtaining a professional degree (e.g., MD, OD, DDS, D Pharm, etc.)? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Maybe Do you plan to get a full-time job in STEM (science, technology, engineering, mathematics) as soon as you complete your undergraduate degree? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Maybe Do you currently have a part-time or full-time job in STEM area? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Maybe; if yes, name of company and position? FORMTEXT ?????_How many hours do you work per week in a typical month? FORMCHECKBOX 0 hours FORMCHECKBOX 1-10 hours FORMCHECKBOX 11-20 hours FORMCHECKBOX 21-30 hours FORMCHECKBOX 31-40 hours FORMCHECKBOX greater than 40 hoursDo you work: FORMCHECKBOX on campus FORMCHECKBOX off campus FORMCHECKBOX I do not workList any STEM clubs on campus in which you are a member: FORMTEXT ?????_____Are you interested in attending the Graduate School Diversity Day Program in November or April (in your junior or senior year)? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Maybe IV. Additional Information - continuedAre you interested in participating in any research training courses to learn how to do research and get placed with a research faculty member? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX MaybeAre you interested in attending a professional STEM conference? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX MaybeAre you interested in presenting an oral presentation at a STEM conference? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX MaybeAre you interested in giving a poster presentation at a STEM conference? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Maybe Are you interested in applying for summer internships or research positions? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX MaybeV. Financial Aid Information – Please Read and Do even if you do not receive financial aid.Regardless of whether or not you are receiving financial aid (which includes scholarships and grants) from Cal State LA, all applicants must PRINT (and SUBMIT with your application) from your GET access the following TWO forms by following these instructions:Use the GET Website () to obtain the following two forms:Academic Year 17-18 formFinancial Aid Summary 17-18 formLog into your GET account.Go to the Student Services Home Link.Go to FINANCES Link.Look under FINANCIAL AID & click on VIEW MY FINANCIAL AID Link.Select the appropriate year you want to look under.Now you will be viewing the FINANCIAL AID SUMMARY 17-18. We refer to this page as the Academic Year 17-18 because it shows everything that you are eligible to receive in 2017-2018 by each semester (PRINT THIS PAGE).Next scroll down near bottom of that same page and click on FINANCIAL AID SUMMARY 17-18.Now you will be viewing your FINANCIAL AID SUMMARY 17-18, which shows your UNMET NEED for both AY17-18 and SUM18 (PRINT THIS PAGE).Submit the two pages that you just printed out to the LSAMP office (ASC-Rosser, Room 360) with the rest of your application.If you are receiving financial aid from Cal State LA, 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).If you are receiving financial aid from Cal State LA, 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.VI. LSAMP APPROVED “MY PLANNER”Follow these instructions and print out your academic plan from GET.Log into your GET account.Go to Student Center.Click on the link titled Plan, which should appear underneath the “Academics” heading to the left of your weekly schedule.Review your Planner very carefully to make sure that all courses remaining for your degree are listed and applied to the specific term that you plan to take the course. As needed, move requirements around to properly reflect what you are taking in fall and spring semesters, 2017-2018 and whether or not you are taking classes in winter 2018 or summer 2018.If you do not have a plan already made, here are the steps to complete one.First, go to your Academic Requirements in the drop down menu in your Student Center to identify remaining requirements that are identified with red boxes.Return to the Plan (see step 3 above)Once in Plan, click on “Browse Course Catalog” to search for each class that you have remaining.Select each class and then click on “Add to Plan until you have selected all of your courses.”All of your remaining requirements should now appear under “Unassigned Courses” on the Plan page.Next step is to assign each of your courses to a specific term by checking the box next to the course and selecting the appropriate term from the pulldown menu directly below the “Unassigned Courses” section. Then click “MOVE.”Every unassigned course should be assigned to a specific term.After you finish, please print and attach to your NEW LSAMP Student Application.VII. Student Signature/ReleasePlease read the statement below and sign where indicated:The information I have submitted in my California State University LSAMP Application is true and accurate to the best of my knowledge. I understand that to track the progress of the CSU-LSAMP students 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 23 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 have read and understand all of the statements above.Typed Name of Applicant: FORMTEXT ?????Signature of Applicant: _____________________________________________ Date: ______________VIII. Campus Coordinator Approval and Certification – Do NOT fill out anything belowThe above named student is approved as a CSU-LSAMP student: FORMCHECKBOX Yes – Is an individual who has faced or faces (check one) FORMCHECKBOX Social FORMCHECKBOX Educational FORMCHECKBOX Economic barriers to careers in STEM FORMCHECKBOX No – Does not meet eligibility criteriaPrinted Name of Campus Coordinator: Dr. Margaret Jefferson or Dr. Katrina YamazakiSignature of Campus Coordinator: _____________________________________Date: ______________IX. Student Acknowledgement – TO BE SIGNED BY STUDENT AFTER APPROVAL FOR PROGRAMI understand that I have been accepted to the CSU-LSAMP Program and granted access to the various activities therein. I further understand that I must maintain expectations explained to me by the CSU-LSAMP Campus Coordinator for continued involvement in the program.Signed: __________________________________________Date: ____________ ................
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