Please Note: This is a sample application for viewing purposes only. This application cycle is currently closed.

Personal Information
First Name:
Last Name:
e-mail:sample-applicant@example.com
Gender: Male
Female
I choose not to specify
Birthdate:
Parent/Guardian Information
Full Name:
Address:
City:
State: Zip:
Home Phone Number:( ) -
Other Phone Number:( ) -
email:
Upon submitting your application your parent/guardian will be sent an electronic request to provide confirmation of their agreement to our involvement in the ASSIST Young Scholars Program if selected. Please inform this individual that he or she will be receiving an email from notices@epsso.net with instructions.

Note: It is the responsibility of the applicant to follow-up with your parent/guardian to ensure that they provide the requested information by Tuesday, April 5, 2022.
Educational Information
School Name:
Current Grade Level:
GPA: on a scale of
Educational Goals:
Primary career interest:
  If Other, Please Specify
Other Activities: List activities or camps you have attended outside of school (such as Upward Bound, SciGirls, Boys/Girls Club or others):
Science Classes: What science classes have you taken? (Select all that apply)
Physical/General Science
Biology
Chemistry
Physics
Earth/Space Sciences
Environmental Science
Anatomy/Physiology
AP Science Class (please enter the name of the class in the text box provided)
      
Other (please enter the name of the class in the text box provided)
      
Math Classes: What mathematics classes have you taken? (Select all that apply)
Algebra I
Algebra II
Algebra III
Geometry
Trigonometry
Advanced Functions/Modeling
Discrete Mathematics
Integrated Math
Pre-calculus
Calculus
AP Statistics or other AP class (please enter the name of the class in the text box provided)
      
Other (please enter the name of the class in the text box provided)
      
Technology/Engineering Classes: Please list any technology or engineering classes that you have taken.
Letter of Recommendation
Important! Letters of recommendation should come from one of your teachers. On giving us the name and email of your recommendees, we will contact them to request them to fill out a form with their reccomendation letter and other information. Please inform them that they will be receiving an email from notices@epsso.net with these instructions. Letters of recommendation are due by Tuesday, April 5, 2022.
Name:
Title:
email:
email confirm:
Other Information
Are you a US Citizen or permanent residet of the United States or its possessions? Yes  No

Why are you interested in being a Young Scholar? (70 words or less)

Explain what makes you a good candidate for ASSIST Young Scholars. (70 words or less)

Describe a favorite activity, lab or project you completed during this school year that relates to science, mathematics, engineering or technology. What did you like best about this project? (70 words or less)

What fields of engineering, science, mathematics, or technology are you interested in and why? (70 words or less)

Who told you about the ASSIST Young Scholars Program?

Other Information
The following questions about ethnic and racial self-identification, and disability status are not criteria for acceptance but for Federal reporting purposes only.
Gender:


Ethnicity:


Race:





Disability Status:



Veteran Status:



Verification
I certify that all the information provided in this application is true to the best of my knowledge.
Please Note: This is a sample application for viewing purposes only. This application cycle is currently closed.