SSTEM Mentoring Program Application

Contact Information

1.

First Name:
Last Name:

2.

Oakton ID:

3.

Permanent Email:

4.

Phone:

5.

Street Address:
City:
Zip Code:

Eligibility

6.

Citizenship:

U.S. Citizen Permanent Resident Refugee Other

7.

My Academic Interest: (Select all that applies.)

Science (biology, chemistry, physics, etc.)

Technology

Mathematics

Science or Math Education

Engineering

Undecided

8.

I am considering the following career(s):

9a.

Describe why you are interested science, technology, engineering, or mathematics: (Be specific.)

Note: This answer is limited to 200 characters. Any responses longer than the default will be truncated to 200 characters.

9b.

Describe your STEM interest in greater detail:

Note: This answer is limited to 200 characters. Any responses longer than the default will be truncated to 200 characters.

10.

List the science, technology, engineering, or math (STEM) courses you are/will be taking in fall 2011:

11.

List the science, technology, engineering, or math (STEM) courses you took in previous semesters:

12.

When do you plan to transfer?

13.

What do you plan to major after transferring?

Additional Information (Optional) Information you provide in this section does not influence your acceptance into the program.

Race

White, non-Latino

Latino

Black

Asian

Other, specify

Prefer not to answer

Gender

Male

Female

Prefer not to answer

Indicate my mentor preference. A mentor is assigned based on your STEM interest, but we will take your preference into account when an option is available.

Same race/ethnicity

Same gender

Same race/ethnicity & gender

Specify mentor:

No Preference

At Oakton, I am a member of: (Select all that applies.)

sports team(s), specify

student organization(s), specify

TRiO

Honors Program

Currently employed? (Select all that applies.)

On Campus Part Time

On Campus Full Time

Off Campus Part Time

Off Campus Full Time

Not Employed

Final Confirmation

By submitting this form, I understand that in order to receive the NSF-Oakton Fellowship, I must successfully complete the program by Dec. 16, 2011. The requirements for SMP include:

• Enrolling in BIO200, CHM200, MAT200, PHY200, ENG200, or CSC200 as recommended by the program coordinator,
• Participating in four activities from a Center for Promoting STEM approved list,
• If engaging in a science, technology, engineering, or math research project, presenting project at end of semester All Students Gathering,
• Passing all enrolled courses of the semester, and
• Enrolling in at least one upper level STEM course.

Will you attend the All Students Gathering on
Wed., Sept. 7, 2011 from 3:00 to 4:30pm at Des Plaines Room 1610.
Wed., Nov. 30 , 2011 3:00 to 4:30pm at Des Plaines Room 1606.

Yes

No

Furthermore, I give Oakton Community College permission to use my biographical information, my essay, and/or photograph in promotional materials, media releases, and other College publications.

Please contact Gloria Liu (847.635.1738, glorial@oakton.edu) if you have any questions.