Level 1 (3.0 GPA – Eligible for activities & stipend)
 Level 2 (<3.0 GPA – Eligible for activities)

			 
First Name:       
Middle Initial:   
Last Name:       

Social Security Number:____________________________________

Banner ID:       
Gender:
 Male   Female
Ethnicity:
 Hispanic or Latino   Not Hispanic or Latino
Race (Choose one or more responses)
Black or African American
Native American
Native of Alaska
Native Hawaiian or Other Pacific Islander
Asian
Race Not Reported or Unknown

Disability Status (Choose one or more responses)
Hearing Impairment
Visual Impairment
Mobility/Orthopedic Impairment
Other
None
Not Reported

Discipline
Chemistry
Computer Science
Information Technology
Life/Biological Sciences
Mathematics

Class (in Major)
Freshman
Sophomore
Junior
Senior

GPA:   
Graduated This Year:  YesNo
Mentor:   
Academic Year Financial Support: Yes(Level 1)No(Level 2)
Summer Financial Support: Yes(Approved Research Travel)No

Below you will find a list of Winston-Salem State University’s activities.  Please select all activities 
in which you will /have participated.

Activity Participation:
(Mark all that apply)

WSSU Conference Travel Support
WSSU – Chemistry Tutorial
WSSU – Computer Sciences Tutorial
WSSU – Life Sciences Tutorial Program
WSSU – Mathematics Tutorial Program
WSSU – Research Experience
WSSU – Stipends and Financial Assistance
WSSU – Summer Gatekeeper Courses
WSSU – Summer Pre-REU

Below is a list of activities reported by our partner institutions.  Please select all activities 
in which you will/have participated.

Partner Activity Participation:    
(Mark all that apply)

GRE Preparation (NC Agricultural and Technical State University
GRE Preparation Workshop (Fayetteville State University)
MEP Minority Overnight Recruitment Weekend (North Carolina State    University)
NC Opt Ed Conference
NC LSAMP Conference
Other LSAMP Conference


	

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