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 withservices that are designed to improve and support the student’s currentacademic performance, and prepare students to enter STEM (Science, Technology,Engineering, Math) careers and/or fields which require professional licensurewithin New York State. LMC STEP activities are funded by New York State grantfunds.

To be eligible for STEP, the student must
- Have a permanent residence in New York State,
- Be enrolled at a New York State school in grade 7-12,
- Be economocially disadvantaged, and
- Interested in pursuing a college major/career in the STEM field or New York State licensed professions.
Disclaimer: You can only be in one New York State opportunity program at a time. If you are enrolled in other NYS programs, please evaluate which single program best meets your needs.
Are you in LPP?*

YesNo
If yes, which one?

LMCOCCSU
Are you in SU STEP?*

YesNo
Student Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
School*

HenningerNottinghamSASOther
Grade*

789101112
Gender*

MaleFemale
School ID # (if available)
What is your current GPA? *
You are required to submit a copy of your most recent high school transcript.
What academic/career field are you interested in?*
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*

Area CodePhone Number
Student Cell Phone*

Area CodePhone Number
Student Email*
example@example.com
Ethnicity*

African American/BlackHispanic/LatinoNative American/Alaska NativeWhite/CaucasianAsianPacific Islander
How did you hear about STEP?*

Poster/Sign/AdvertisementClassroom PresentationTeacher/Guidance CounselorStudent (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!
Parent/Guardian Information

Information Gathered by New York State
Parent/Guardian Name*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Phone Number 1*

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

Area CodePhone Number
Parent/Guardian Email*
example@example.com
Household Size*
Household Income*
Le Moyne College STEP General Parental Permission
Student Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I, Parent First Name Parent Last Name, give permission for my child,Student First Name Student Last Name, 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 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, allergies, or food restrictions (cultural, religious, orallergies): Example: Some cultural or religious diets do not consume pork or shellfish. Please list any foods that you cannot consume due to allergy, cultural norms, and/or religious beliefs. *
Parent/Guardian Signature*

First NameLast Name
Date*

MonthDayYear
Date
Emergency Contact Information
Emergency Contact 1 Name*

First NameLast Name
Emergency Contact 1 Phone Number*

Area CodePhone Number
Emergency Contact 1 Email*
example@example.com
Relationship to Student*
Emergency Contact 2

First NameLast Name
Emergency Contact 2 Phone Number

Area CodePhone Number
Emergency Contact 2
example@example.com
Relationship to Student
AUTHORIZATION FOR DISCLOSURE OF EDUCATIONAL INFORMATION
I am the legal parent or guardian for   Student First   Student Last   and I authorize Le Moyne Science & Technology Entry Program to
o  Obtain information from   Student's School*

o  Release information to: Le Moyne Science & Technology Entry Program, 1419 Salt Springs Road, Syracuse, NY 13214

I hereby authorize the disclosure of educational information between the Science and Technology Entry Program (STEP) and the School district indicated above, in accordance with the Family Educational Rights and Privacy Act (FERPA).

Specific information to be released or obtained includes the following confidential
information necessary for educational services:
- Student standardized test scores, Grades, and Report Card Information
- Individual course communications, assignments, and interim results
This information is required for the purpose of any necessary and ongoing educational needs inclusive of evaluations and recommendations for further development.

By signing below I am stating that:
- I understand the information disclosed, as permitted by this authorization, will not be re-disclosed by the receiving entity (and/or its affiliates). I understand that local, state, and federal laws do exist to protect the confidentiality of this information.
- I understand that I have the right to revoke and/or restrict this authorization at any time without penalty, provided that I submit a request in writing to the LMC STEP Office.
- I authorize the periodic, on-going disclosure of the above information. This authorization expires upon the student’s graduation or exit from Le Moyne College Science & Technology Entry Program.
LMC STEP STUDENT EXPECTATIONS
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 understand that all Le Moyne College STEP students are required to attend an orientation or 1:1 meeting with STEP staff to review program activities, complete the Student Agreement (shown below), and other program documentation.

Student Agreement

1.    I agree to maintain a grade point average of 70 % in all of my Regents Math and Science courses and an overall grade point average of 70% throughout my high school career. I also understand that the STEP program expects me to try to earn an Advanced Regents Diploma.

a.    At minimum I agree that STEP expects me to attain grade improvement in each class and overall.

2.    I agree to take Regents-level Math and Science courses throughout high school to prepare myself to enter college, STEM-related careers or other New York State licensed professions.

3.    I agree to participate in a minimum of 2 STEP activities per month. STEP activities include the following:

a.    After school programs

d.    Monthly STEP Luncheons

e.    STEP Saturday Institute (21 Saturdays/academic year)

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 an Academic Improvement Plan 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.

6. I understand that my progress will be monitored throughout my enrollment in the program and that I am expected to meet specific program requirements outlined in the STEP Student Agreement.

By submitting this application, I confirm that I have reviewed the Le Moyne College Science and Technology Entry Program Student Expectations. My signature and that of my parent/guardian constitute an agreement between us and the Le Moyne College Science & Technology Entry Program.
Student Signature*

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Date*

MonthDayYear
Date
Parent Signature

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Parent/Guardian Signature*

First NameLast Name
Date*

MonthDayYear
Date
Contact Information

STEP
Le Moyne College
1419 Salt Springs Road, Romero Hall
Syracuse, New York, 13214

315-445-4263
Email: step@lemoyne.edu
Should be Empty:

Le Moyne College Science and Technology Entry Program Application

Student Information

Parent/Guardian Information

Le Moyne College STEP General Parental Permission

Emergency Contact Information

AUTHORIZATION FOR DISCLOSURE OF EDUCATIONAL INFORMATION

LMC STEP STUDENT EXPECTATIONS