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
Date*

MonthDayYear
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?*

YesNo
Social Security #*
Please upload photo of student social security card. *
Home Schooled?*
School *
Ethnicity*

Black/African AmericanWhiteHispanic or LatinoAsianAmerican Indian or Alaskan NativeNative Hawaiian or other Pacific Islander
Current Grade*

7th8th9th10th11th12th
English Language Learner*

YesNo
Does Student Have a Disability?*

YesNo
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?*

YesNo
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*

Clear
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*

Clear
** 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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