MSA Application

Date of Program: June 8-12, 2009
All applications must be received by May 8, 2009.

Name:
Date of Birth:
Street Address:
City:
State:
Zip Code:
County of Residence:
High School:
Home Phone:
Cell Phone:
E-mail Address:
Social Security or EKU ID Number: (Required)
Parent or Guardian:
Please list the names, phone numbers and e-mail addresses of two references familiar with your academic work in mathematics or science and/or your interest and ability in mathematics, science, or the health sciences. These individuals should complete the reference form and return it by Friday, May 8, 2009.
Reference 1 Name:
Home Phone:
E-mail Address:
Reference 2 Name:
Home Phone:
E-mail Address:
Please answer the following questions. List the science courses you have taken in high school and the grades you received in each course. Please include current courses in which you are enrolled and the grades you expect to receive.
Write why you are interested in participating in the Eastern Kentucky University Mathematics & Science Academy, and how you hope to contribute to the program.