STEP Program Participant Application Form

Student Application

STEP Program at Buffalo State College

1300 Elmwood Ave. (Buckham Hall A106)

Buffalo, New York 14222

Science Technology Entry Program at Buffalo State College

STEP MISSION

To increase the number of historically underrepresented and economically disadvantaged students prepared to enter college, and improve their participation rate in mathematics, science, technology, health-related fields, and the licensed professions

Eligibility

To be eligible for STEP, students must be:

New York State residents
Enrolled in grades 7-12
Economically disadvantaged and/or
In need of, or would greatly benefit from, academic enrichment or support in the STEM areas (to be determined locally)
Economically Disadvantaged:

For the purpose of STEP, a student is economically disadvantaged if he or she meets the income eligibility criteria (2022-28 STEP Income Eligibility Criteria). The eligibility standards set forth apply only at the time of admission as a first-time student to a STEP program. Once admitted, a student may continue to receive supportive services as needed, even if the family income rises above the current eligibility standards.

Additional documentation of household income need not be collected to determine eligibility under economic disadvantage if the student falls into one of the following categories, and documentation is available to demonstrate:

▪️the student's family is the recipient of family assistance program aid or safety net assistance through the New York State Office of Temporary and Disability Assistance or a county department of social services; or is the recipient of family day-care payments through the New York State Office of Children and Family Services or a county department of social services;

▪️the student is living with foster parents and no monies are provided from the natural parents;

▪️the student is a ward of the State or a county.

▪️the student is eligible for free or reduced lunch at his or her secondary school based upon family income (verified by the school).

Date

First Name

Middle

Last

Date of Birth

Sex

Student Email

Parent/Guardian Name

Home Phone Number

Parent Email

example@example.com

Street address

Street address line 2

City

State

Zip code

New York State Resident?

Social Security #

Please upload photo of student social security card.

Home Schooled?

School

Ethnicity

Current Grade

English Language Learner

Does Student Have a Disability?

If yes please list disability

Does Student Have Allergies

If Yes Please List allergies

Any Medial Conditions to be aware of please list all.

Documentation is required verifying economic status for all students.

Is Student Eligible for free or Reduced Lunches?

If yes, please upload proof of free lunch eligibility.

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House Hold Size # of Family Members living in Home

Household Income Yearly Amount including all

The following is acceptable proof of documentation:

A. Appropriate years tax forms (last filed)

B. W2's

C. IRS non filer form 1722 or no income IRS form 4506

D. Pension, Annuity, Unemployment benefits letter showing appropriate year

E. Social Security, Supplemental Security, Veterans benefits, Medicare

F. Social Service Payments, Disability, Office of Children and Family Services

G. Child Support and/or Alimony, Court Order, Affidavit

H. Documentation of additional members third party verification with proof of income

I. Documentation of zero household contribution States Education Department

Please upload proof of income

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EMERGENCY CONTACT

Name

Relationship

Address

City

State

Zip code

Phone number

Academic Information

Pre Assessment Performance

A COPY OF REPORT CARD MUST BE SUBMITTED EVERY TERM

Current Math Grade/Average

Current Science Grade/Average

Last Quarter GPA/Average

All previous math courses taken

All previous science courses taken

If known, what college/s would student like to attend?

What field of study/career interest?

FIELD TRIP PARTICPATION FORM

I (Parent/Guardian) give my child permission to accompany the STEP Program on field trips during the academic year. I authorize the STEP Program to be released from any claim of accident and/or injury that may occur to my child during his/her participation and while utilizing transportation services provided by the program. Also, I am advised that STEP Program is not responsible for any loss or damage to student possessions during the course of this trip.

Signature

RULES AND REGULATIONS

1. Must arrive to tutoring as soon as school is released for the day

2. Proper behavior is required.

3. No hats to be worn during tutoring, workshops and/or seminars

4. Music players, headphones etc are NOT allowed during tutoring, workshops and/or seminars unless for reasearch purposes or homework

5. All students must come prepared and participate in all STEP related activities, field trips, workshops unless granted special permission by program administration.

Violations of this contract will be investigated and could result in your immediate dismissal from the STEP Program

PERMISSION RELEASE

I (Parent/Guardian) give permission for this student to pariticpate in the Science Technology Entry Program at Buffalo State College (STEP). I grant the program to collect :

School Report Cards, transcripts, standardized test scores, SAT/ACT scores

Share Student Name and Contact Information with CSTEP Program and College University Admissions Offices

Photo release for program promotions and/or events

Signature

** Please click and download the W-9 form below, fill it out, and upload the completed copy. Must enter the students social security number on the form.**

W9 Form

Upload W9 Form Here

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