SUNY Irises Application 2022

SUNY Irises Application 2022
Student Eligibility:
1. New York state resident.
2. Full time SUNY Optometry student, during our CSTEP program.
3. African-American, Hispanic/Latino, American Indian or Alaskan native
4. If you are not African-American, Hispanic/Latino, American Indian or Alaskan native, you can qualify as an economically disadvantaged student. Please refer to this chart.
Upon completing this initial application and submission, you'll get an email for the following documents, so please make sure you start obtaining them:
1. Current College Transcript (unofficial transcript is acceptable).
2. Current class schedule or course registration.
3. Document verifying household income (i.e. most recent IRS 1040 form) – only if you are not African-American, Hispanic/Latino, American Indian or Alaskan native.
4. W9 form (your information, not your parents')
* Denotes a required field.
First Name*
Middle Name*
Last Name*
Present Address
Address*
Apt
City*
State*
Zip Code*
Telephone*
Email*
example@example.com
Date of Birth*

MonthDayYear
Date of Birth
Permanent Address (if different)
Address
Apt
City
State
Zip Code
Legal State of Residence*
Country of Birth*
If permanent registered alien, Registration Number
Ethnicity*

AsianNative Hawaiian or other Pacific IslanderAfrican-American/BlackWhite/CaucasianHispanic/LatinoNative-American Indian/Alaskan
Sex*

MaleFemaleX
“X” may be used by and individual to indicate sex or gender where they feel “male” or “female” would not be appropriate. “X” may include, but is not limited to, the following:
- Transgender
- Trans man
- Trans woman
- Non-binary
- Gender non-conforming
- Agender
- Bigender
- Pangender
- Questioning or unsure
- Prefer not to specify
Education
Are you a first generation college student?*

YesNo
Year first matriculated into optometry school*
Are you a transfer student?*

YesNo
If yes, which institution
School Currently Attending*
Class Level *
ex: Fr, So, Jr, Sr
Expected Date of Graduation*

MonthDayYear
Expected Date of Graduation
Undergraduate GPA:
Optometry School GPA:
Optometry School GPA:
Optometry School GPA:
Parental Information
Father's Name*
Mother's Name*
Total Annual Family Income*
Number of Members in Household*
Sources of Income*
Have you ever participated in any of the following state-sponsored programs in the past?

P-TECHSmart Scholars Early College High SchoolLPPSTEPCSTEPEOPSEEKCollege DiscoveryHEOPOther New York State Opportunity Programs
If you participate in any of the above programs at your school, please list: 1) Name of program, director or coordinator’s name, their phone number, and date(s) you were in program.

0/500
NOTE: Being a member of CSTEP at another College does not preclude you from participating in SUNY Optometry’s CSTEP Internship Program.
Please list any involvement you have had at SUNY Optometry that works to support under-represented minority (URM) students at SUNY or high-need populations at large. Some examples include: if you are involved in NOSA/NOA in any capacity, if you are a member of the Task Force for Race & Equity, or if you’ve volunteered for homeless shelters, or have gone on a SVOSH trip to help high-need communities.*

0/500
From what you know about our SUNY Irises program, please explain how being in this program formally will benefit you in your professional pursuits. If relevant, please describe the role you have played in and/or hope to play in working with underrepresented minority students and high-need communities in your professional career (up to 500 words).

0/500
Please verify that you are human*
Should be Empty:

SUNY Irises Application 2022

Present Address

Permanent Address (if different)

﻿Education

﻿Parental Information

Education

Parental Information