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KENTUCKY STATE UNIVERSITY

June 23rd to July 14th, 2024

Eligibility Requirements:

First name Middle name Last name

Email___

Street ___ Apt #___

City _____ State _____ ZIP _____

County_____ Phone_____

Social Networking Facebook □ Instagram □ Twitter □ Other □

Race/Ethnicity ___

Gender ☐ Female ☐ Male Birthdate (MM/DD)___ ___

Age (by June 23, 2024) ___ T-shirt Size ___

Name of the school you currently attend: ___

___

Grade level completed by June 23rd, 2024 └── 10th └── 11th

Expected Graduation Date: Month/Year___

(Roommate requests are accommodated when both individuals mutually request each other)

If possible, I would like to room with:

First name Middle name Last name ___

Evening phone_____

Day phone_____

Cell phone_____

Email___ First name Middle name

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First name Middle name Last name

Last name

Evening phone_____

Day phone_____

Cell phone_____

Email ___

This program is supported by National Science Foundation Historically Black College and Universities-Undergraduate Program (NSF-HBCU-UP) to promote minority students' participation in STEAM-undergraduate degree programs.

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Respond to prompts #1-4 on separate sheets of paper and be sure to include your name on each sheet.

___Aquatic Ecosystems

___Fish Genetics

Aquaponics

__Identifying Fish Diseases

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Ask your current science and math teachers to complete this section. A typed recommendation can be attached if available, but please ensure signatures are on the application.

Summer Apprenticeship Program (SAP) at Kentucky State University is a competitive scholarship program that offers participants college preparation, STEM education and career exploration, and research opportunities. Students should be recommended if they are motivated and interested in experiential STEM learning and research.

Comments (to be completed by a Math or Science teacher that can attest to your preparedness in the STEM fields)

Teacher Signature ___ Title ___ Date ___ / ___ /

Teacher Printed Name, Phone, and Email ___

Comments (to be completed by any teacher or administrator that can attest to your work ethic and development as a student)

Teacher Signature ___ Title ___ Date ___ / ___ /

Teacher Printed Name, Phone, and Email ___

Enclose your latest official transcript, covering all coursework through the first semester of this year, and have your Guidance Counselor specify the following:

Cumulative GPA___

(Note: If your school uses a grading system other than the 4.0 scale, an explanation of the method must accompany the official transcript).

Counselor Name (printed)___Signature___Date___/___/___Counselor Email:___

□Counselor or Teacher □KSU website □Email □Friend □Church □Recruiting Event □KSU recruitment activity Prior participant (in KSU youth programming): Program(s) _____ Year(s) Attended _____ Other sources (please specify)

Other sources (please specify)___

I authorize of my son/daughter to submit this application for the KSU Summer Apprenticeship Program. I understand participants are selected on a competitive basis, so not everyone will be accepted for the program.

Parent Signature\_\_\_ Date\_\_\_ / \_\_\_ /

_____

Applicant Signature\_\_ Date / /

Submit to by email to buddhi.gyawali@kysu.edu or mail to: Dr. Buddhi Gyawali Director of SAP and Professor of Geospatial Applications 400 East Main Street Cooperative Extension Building Room 225 Kentucky State University, Frankfort, KY 40601 This institution is an equal opportunity provider.