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NC State University SPARCS Outreach Application [2017]
This is the 2016- application for students who are interested in joining the SPARCS Outreach program at NCSU. Any questions should be emailed to
sparcs.outreach@gmail.com
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* Indicates required question
Student Last Name
*
Your answer
Student First Name
*
Your answer
Student Email Address
*
Your answer
Current School
*
for the 2016-2017 school year
Your answer
Grade Level
*
Choose
6
7
8
Date of Birth (month/day/year)
*
(mm/dd/yyyy)
MM
/
DD
/
YYYY
Gender
*
Choose
Female
Male
Race/Ethnicity
*
Choose
African-American
American Indian or Alaskan Native
Asian
Bi or Multi-Racial
Caucasian
Hispanic
Pacific Islander
Has your mother or father graduated from a four-year college or university?
*
Yes
No
Home Phone Number
*
(xxx-xxx-xxxx)
Your answer
Do you live with both parents?
*
Yes
No
If not, with which parent do you reside?
Mother
Father
Clear selection
Name of mother/female guardian
Your answer
Mother's E-mail Address
(please give an e-mail address that you check often)
Your answer
Mother's Contact Phone Number
(xxx-xxx-xxxx)
Your answer
Name of father/male guardian
Your answer
Father's E-mail Address
(please give an e-mail address that you check often)
Your answer
Father's Contact Phone Number
(xxx-xxx-xxxx)
Your answer
Student's Career Interest
*
Your answer
Short Answer Prompt
*
All students must submit a one-paragraph, student-written response describing how this program will benefit your academic future. Middle school students' response should be a minimum of 35 words.
Your answer
Please submit all materials together either electronically to
sparcs.outreach@gmail.com
, or in person at the Center for Educational Informatics (NC State University)
*
All materials below must be submitted by September 14.
Liability Waiver
Required
In case of emergency, who should we notify?
*
Please provide Name, Phone number, Relation for each contact listed
Your answer
Are there any medical conditions, behavioral conditions, or allergies instructors should be aware of?
*
Your answer
As a part of the program, pictures may be taken and used for SPARCS related material including but not limited to: research, posters, promotional material. Please indicate below whether you give consent to having the student's picture be taken and used for SPARCS related materials and events.
*
Yes
No
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