Arizona State University



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TRiO SSS GATE 2010 Application

July 18, 2010 – July 24, 2010

|Personal Information |

|Name: |

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|Mailing Address (local): |

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|City/State/Zip: |

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|Permanent Address: |

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|City/State/Zip: |

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|Home phone: |Student Email: |

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|Cell phone: |Student ASU Email (if available): |

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|Date of Birth: |Parent Email: |

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|Gender: |ASU ID # (10 digit): |

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|High School Information |

|Name of High School: |Year of Graduation: |

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|Address: |City/State/Zip: |

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|High School GPA: |

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|SAT Score: |ACT Score: |

|Verbal       Math       |Verbal       Math       |

|Class Ranking: |

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|Have you taken any dual enrollment/AP courses? YES NO If yes, please list the course and grade earned. |

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|College Information |

|Have you already been admitted to ASU? Yes No |

|Are you registered with the Disability Resource Center ? Yes No (You MUST be registered to be eligible for GATE 2010) |

|Intended major at ASU:                           |

|What campus will you be attending in the fall? |

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|Tempe Campus West Campus Polytechnic Campus Downtown Phoenix Campus |

|Do you have a FAFSA on file? Yes No |

|Are your MMR records on file with the ASU Health and Wellness Center? Yes No |

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|TRiO SSS Information |

|What previous enhancement services (e.g. counseling, tutoring, and study skills assistance) have you received in elementary school, high school, or college? |

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|Would you like to work with an instructional specialist to learn disability specific strategies in math, reading, social science or and/or writing? Yes No |

|Please check the box for courses for which you would like to request tutoring: |

|Biology Chemistry Communications |

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|Math Psychology/Sociology |

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|Reading Writing Other: |

|Please check areas in which you would like assistance, instruction or information: |

|Career Guidance Financial Aid Reading Stress Management Writing Math Study Skills |

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|Time Management Coping with College Other: |

|Essay – IMPORTANT! Please be thoughtful in your response. |

|In one or two paragraphs, please explain how your participation in GATE 2010 will help you meet your academic and career goals. Include information about special |

|circumstances or challenges that you would like the committee to take into consideration in reviewing your application. |

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By submitting this application, I agree to the following: If accepted into the GATE 2010 program, I will attend ASU during the fall semester. On behalf of the Family Education Rights and Privacy Act of 1974, I hereby authorize the release of my records in reference to academic transcripts, degree plans, personal assessment test scores, and any other academic related information to the DRC and TRiO staff.

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Student Signature Date

A complete GATE 2010 application consists of:

1. This completed and signed form

2. A copy of the first two pages of the parent/s 2009 tax return

You may submit your application packet by email, US Mail or fax. THE APPLICATION DEADLINE is May 15, 2010.

Email: karen.caldwell@asu.edu

US Mail:

Karen Caldwell/GATE

PO Box 873202

Tempe, AZ 85287-3202

Fax: 480-965-0441

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