Le Moyne College Science and Technology Entry Program Application

Le Moyne College Science and Technology Entry Program Application

The Le Moyne Science and Technology Entry Program (STEP) provides students with services that are designed to improve and support the student's current academic performance, and prepare students to enter STEM (Science, Technology, Engineering, Math) careers and/or fields which require professional licensure within New York State.
Disclaimer: You can only be in one New York State opportunity program at a time
Are you in LPP? *

Yes No
If yes, which one?

LMC OCC SU
Are you in SU STEP? *

Yes No
If you are in other New York State programs, you need to evaluate which single program best meets your needs.
Student Information
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
School *

Henninger Nottingham SAS
Grade *

8 9 10 11 12
Gender *

Male Female
School ID # *
What is your current GPA? *
What STEM field/career are you interested in? *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone *

Area Code Phone Number
Cell Phone *

Area Code Phone Number
Email *
example@example.com
Ethnicity *

African American/Black Hispanic/Latino Native American/Alaska Native White/Caucasian* Asian/Pacific Islander*
* Per state mandate, additional documentation required:
1. Verification of Family Income
2. Reduced or Free Lunch Eligibility Paperwork (if applicable)
US Citizen: *

Yes No
Permanent Resident: *

Yes No
Last 4 SS#: *
Length of Residency in New York State: *
Country of Birth *
Parent/Guardian Information

Information Gathered by New York State
Parent/Guardian Name *

First Name Last Name
Relationship to Student *
Parent/Guardian Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian Phone Number 1 *

Area Code Phone Number
Parent/Guardian Phone Number 2 (If Applicable)

Area Code Phone Number
Parent/Guardian Email *
example@example.com
Household Size *
Household Income *
How did you hear about STEP? *

Poster/Sign/Advertisement Classroom Presentation Teacher/Guidance Counselor Student (List below) Other (List below)
If "other," please explain
If "Student," please list the name of the referring student for our referral incentives program. You both benefit!
Le Moyne College STEP Student Agreement Form
I agree to participate in the Science and Technology Entry Program (STEP) sponsored by Le Moyne College. I understand that the purpose of the STEP program is to help me develop my academic skills and explore professional careers in Science, Technology, Engineering, Math (STEM) and Licensed professions. I also realize that other support services (SAT and Regents exam prep, advising, mentoring, job shadows, College Success Seminars and STEM Academy enrichment activities) will be offered to me.
1. I agree to maintain a grade point average of 80 % in all of my Regents Math and Science courses and an overall grade point average of 80% throughout my high school career. I also understand that the STEP program expects me to try to earn an Advanced Regents Diploma.
2. I agree to take Regents-level Math and Science courses throughout my four years of high school to prepare myself to enter college and STEM-related or other licensed careers. I will provide a copy of my grades, every marking period, to the Le Moyne College STEP program.
3. I agree to participate in at least one monthly academic advising session with STEP staff, to participate in tutoring/mentoring two or more times per week and to attend College Success Seminars and/or STEM Academy activities two or more times a month.
4. I agree to respect myself, my peers, and the STEP staff at all times. In addition, I agree to arrive on time and dress appropriately for all STEP activities.
5. I understand that I can be put on probation or dismissed from the program for failing to maintain STEP academic requirements, for violating the STEP behavioral expectations or for not fulfilling STEP program obligations.
My signature and that of my parent/guardian constitute an agreement between us and the Le Moyne College Science and Technology Entry Program. I have read this document and understand my responsibilities.
Student Signature *

First Name Last Name
Date *

Month Day Year
Date
Parent/Guardian Signature *

First Name Last Name
Date *

Month Day Year
Date
Media Release

Sign if you agree
I grant permission for my student’s photograph, whether still, motion, digital or television, writings, and/or recordings of his or her voice taken during the course of the program to be used in future STEP publications and promotions.
Parent/Guardian Signature *

First Name Last Name
Date *

Month Day Year
Date
Le Moyne College STEP General Field Trip/Special Event Parental Permission
Student Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I give permission for my child to participate in all Le Moyne College Science and Technology Entry Program (STEP) field trips and activities (both in school and off school campus).

I also give permission to the STEP staff to transport and to arrange for medical attention in case of a medical emergency.
Insurance Name *
Policy Number *
Policyholder *
Please list any illnesses or allergies that we should be aware of: *
Parent/Guardian Signature *

First Name Last Name
Date *

Month Day Year
Date
Emergency Contact Information
Contact 1
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email *
example@example.com
Relationship to Student *
Contact 2
Name

First Name Last Name
Phone Number

Area Code Phone Number
Email
example@example.com
Relationship to Student
Contact Information

Jordan Law
Assistent Director
CSTEP and STEP
Le Moyne College
1419 Salt Springs Road, Romero Hall
Syracuse, New York 13214
lawjl@lemoyne.edu
(315) 445-4655 (Phone)
Should be Empty:

Le Moyne College Science and Technology Entry Program Application

Student Information

Parent/Guardian Information

Le Moyne College STEP Student Agreement Form

Media Release

Le Moyne College STEP General Field Trip/Special Event Parental Permission

Emergency Contact Information