Document 363864
PRE-APPLICATION FORM (MS) 2 Mathematics & Science for Minority Students Please mail this signed 2-page Pre-Application Form along with the student essay by or on November 20, 2014. We cannot accept late Pre-Application Forms. STUDENT INFORMATION Student’s name __________________________________________________________ n M n F Birth date____ /____ /_______ First Middle Last Mailing address ______________________________________________________________________________ Apt._______________ City_______________________________________________________________ State__________________ Zip_________________ ALIllinois AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Rhode Iowa Florida New Idaho Indiana Hawaii South Kansas Alabama Louisiana Michigan Pennsylvania Texas Connecticut Arizona Delaware Kentucky Nebraska Arkansas Wisconsin Vermont Utah California Tennessee Alaska Mississippi Oregon New Virginia District Georgia North Colorado Oklahoma Nevada Maine Montana New Ohio Massachusetts Wyoming Maryland Minnesota New Missouri Washington West Jersey York Hampshire Mexico Carolina Dakota Island Virginia Carolina Dakota of Columbia Home phone (_________)______________________________ Student’s cell phone (_________)____________________________ Student e-mail_________________________________________________________________________________________________ Ethnicity of Student Applicant: n African American n Latino/a n Native American______________________________________ SCHOOL INFORMATION Tribal affiliation (Note: Private school students are not eligible) Present public high school_________________________________________________________ Student is currently in grade________ School address_________________________________________________________________________________________________ City_______________________________________________________________ State__________________ Zip_________________ ALIllinois AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Rhode Iowa Florida New Idaho Indiana Hawaii South Kansas Alabama Louisiana Michigan Pennsylvania Texas Connecticut Arizona Delaware Kentucky Nebraska Arkansas Wisconsin Vermont Utah California Tennessee Alaska Mississippi Oregon New Virginia District Georgia North Colorado Oklahoma Nevada Maine Montana New Ohio Massachusetts Wyoming Maryland Minnesota New Missouri Washington West Jersey York Hampshire Mexico Carolina Dakota Island Virginia Carolina Dakota of Columbia Guidance counselor name_____________________________________________________ n Public school n Public charter school First Last Counselor E-mail_____________________________________________________ Counselor fax (_________)____________________ Counselor phone_____________________________________________________ School phone (_________)____________________ PARENT/GUARDIAN INFORMATION n Mother Deceased n Father Deceased PARENT/GUARDIAN 1 PARENT/GUARDIAN 2 Name________________________________________________ Name________________________________________________ n Father n Mother n Guardian n Father n Mother n Guardian Marital status (check all that apply): n Married n Single n Separated n Divorced n Cohabitating n Widowed Marital status (check all that apply): n Married n Single n Separated n Divorced n Cohabitating n Widowed Address_______________________________________________ Address_______________________________________________ ____________________________________________________ ALIllinois AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Rhode Iowa Florida New Idaho Indiana Hawaii South Kansas Alabama Louisiana Michigan Pennsylvania Texas Connecticut Arizona Delaware Kentucky Nebraska Arkansas Wisconsin Vermont Utah California Tennessee Alaska Mississippi Oregon New Virginia District Georgia North Colorado Oklahoma Nevada Maine Montana New Ohio Massachusetts Wyoming Maryland Minnesota New Missouri Washington West Jersey York Hampshire Mexico Carolina Dakota Island Virginia Carolina Dakota of Columbia Home phone (_________)_______________________________ ____________________________________________________ ALIllinois AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Rhode Iowa Florida New Idaho Indiana Hawaii South Kansas Alabama Louisiana Michigan Pennsylvania Texas Connecticut Arizona Delaware Kentucky Nebraska Arkansas Wisconsin Vermont Utah California Tennessee Alaska Mississippi Oregon New Virginia District Georgia North Colorado Oklahoma Nevada Maine Montana New Ohio Massachusetts Wyoming Maryland Minnesota New Missouri Washington West Jersey York Hampshire Mexico Carolina Dakota Island Virginia Carolina Dakota of Columbia Home phone (_________)_______________________________ Work phone (_________)________________________________ Work phone (_________)________________________________ Cell phone (_________)_________________________________ Cell phone (_________)_________________________________ E-mail_______________________________________________ E-mail_______________________________________________ First Last First Last Continued (MS)2 PRE-APPLICATION FORM Continued STUDENT ESSAY On this form or on a separate sheet of paper, please type a short essay (approximately 500 words) about why you are interested in participating in (MS)2. If you include a separate sheet of paper, be sure to type your name and the date at the top of your essay. In particular, you should talk about: • How did your interest in math and science start? Why do you enjoy math and science? What type of math or science do you like best? • As an African American, Latino/a, or Native American, how do you feel the (MS)2 program would benefit you? • Tell us about yourself, including where you live and what your life is like. Student’s name___________________________________________________________ Signature of student_______________________________________________________Date_________________________________ Signature of parent/guardian________________________________________________ Relationship to student__________________ Please mail this signed 2-page Pre-Application Form and the student essay, postmarked by or on November 20, 2014, to: (MS)2 Phillips Academy 180 Main Street Andover MA 01810–4161
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