Personal Information

First Name
Last Name
Middle Initial
Street Address
Address (cont.)
City
State
Zip Code
Country
Home Phone
E-mail
URL

Date of Birth
Sex	Male    Female
Social Security Number

Ethnicity:    
Native American     White      African American  Hispanic                Asian     Other

Academic Information
What school do you currently attend?

What school district do you currently attend?

What is your grade level?  7th 8th 9th 10th 11th 12th
What is your Grade Point Average? 
What is your class rank? 

Academic Information
What school will you attend next year?

What district will you be attending next year?

Next year you will be in grade:  7th 8th 9th 10th 11th 12th College Other

Pre-college Preparation Information
What pre-college math courses have you completed?

Pre-Algebra
Algebra I
Algebra II
Geometry
Trigonometry
Pre-Calculus
Calculus
Analytical Geometry
Statistics

What Pre-College science courses have you completed?

Earth Science
Life Science
Biology
Chemistry I
Chemistry II
Anatomy
Physics I
Physics II

What computer science courses have you taken?

BASIC
C or C++
Pascal
Turbo Pascal
Java
Visual Basic
Cobol
FORTRAN

Outside Activities

Please list any organization you are involved in:

Who is the current president of this organization?

What is the organization's address (include street number, city/state, and zip)?

Does this organization have a website? If so please input it here:

What are the goals of the organization?

List any leadership positions you have held with this organization?

Does this organization support programs such a TexPREP? If so, is it though:

Donation
Student Scholarships
Staff Support
Fund raising efforts
Foundation

Honors

Please list any awards, scholarships, or accomplishments that you have attained:

Impact of PREP

Please describe the impact that TexPREP had on you academically or personally.

Please describe what you valued most about the program:

Other Comments or Suggestions

Please list any other comments or suggestions: