Application form the timbuktu academy

Diola Bagayoko, Ph.D., Director

T
 SUMMER BRIDGE INSTITUTE (SBI)

 Undergraduate Research Program (URP)

Southern University and A & M College

P. O. Box 11776 - Baton Rouge, LA 70813

Phone: (225) 771-2730 Fax: (225) 771-4341

e-mail: timbuktu.academy@grant.phys.subr.edu

PERSONAL DATA

Name (last, first, middle):

Social Security No.:

E-mail Address (Important):

Date of Birth:

Mailing Address:

City:

State:

Zip Code:

Home Phone:

( )

*Specify Gender:

Male Female

Permanent Address (if different from above)

City

State

Zip Code

Permanent Contact Phone Number

( )

*Ethnicity (Check all that apply.):

African American

Asian American

Hispanic American

Native American

White American/Caucasian

Other _____________

*This optional information has no bearing on the selection process. It is strictly for statistical purposes.

Citizenship

U. S.

Permanent Resident

Other

(MUST BE A U.S. CITIZEN OR PERMANENT RESIDENT)

EDUCATION RECORD

High School (2000-2001):

Expected Graduation Date:

GPA:

(ATTACH A COPY OF AN OFFICIAL HIGH SCHOOL TRANSCRIPT)

(Intended) Major:

Current Grade

 HS-Sr.

 CO-Fr.

 CO-So.

 CO-Jr.  CO-Sr.

LEGEND: HS- High School * CO - College * Sr. - Senior * Fr. -Freshman * So.- Sophomore * Jr. - Junior

PARENT/GUARDIAN INFORMATION

MOTHER

Name

Address (if different from above)

Daytime Phone Number

FATHER

Name

Address (if different from above)

Daytime Phone Number

Highest grade completed by

MOTHER

FATHER

ACT SCORES: Composite: _______ English: ________ Math: _______ Reading: _______ Sci. Reas. _____ SAT: Verbal _______ Math ______

MAIL COMPLETED APPLICATIONS TO: Dr. Diola Bagayoko Director, Timbuktu Academy P. O. Box 11776 Baton Rouge, LA 70813

FOR OFFICE USE ONLY: Date Received: _________________ Status: ________________________ Letter:_________________________

APPLICATION DEADLINE: MARCH 30, 2003 for SBI, Applications are accepted year round for URP

Student's Signature

Parent's Signature

Date

Date

APPLICATIONS ARE DEEMED INCOMPLETE UNLESS ACCOMPANIED BY A SHORT ESSAY, THREE LETTERS OF RECOMMENDATION, ACT/SAT SCORE REPORT, RESUME AND AN OFFICIAL HIGH SCHOOL TRANSCRIPT.

FUNDED BY THE DEPARTMENT OF THE NAVY, OFFICE OF NAVAL RESEARCH (ONR) - Page 1 of 2

SBI/URP APPLICATION				Page 2
REFERENCES
Please list below the name, title/affiliation, and office phone number of the three (3) individuals you have asked to write a letter of recommendation. NOTE: INDIVIDUALS MUST BE HIGH SCHOOL OR COLLEGE SCIENCE, ENGLISH, MATHEMATICS, OR ENGINEERING TEACHERS/INSTRUCTORS.
Name		Title				Telephone
Name		Title				Telephone
Name		Title				Telephone
ESSAY
On a separate sheet, please describe your career goals, interest in science, and previous science experiences (science fairs/rallies, summer research, summer enrichment, etc., if any.
CHECK LIST
This application must have the following documents attached:
	Official high school transcript Three letters of recommendation Essay (See Section Above) ACT/SAT score report (all pages) Resume' (See sample resume' at our website http://www.phys.subr.edu/timbuktu.htm) SUBR Admissions application, if not previously submitted (for SBI applicants only) APPLICATION DEADLINE: MARCH 30, 2003 for SBI The application and addition information on the Timbuktu Academy may also be obtained via the home page of the Timbuktu Academy: http://www.phys.subr.edu/timbuktu.htm
APPLICATIONS ARE DEEMED INCOMPLETE UNLESS ACCOMPANIED BY A SHORT ESSAY, THREE LETTERS OF RECOMMENDATION, ACT/SAT SCORE REPORT, RESUME AND AN OFFICIAL HIGH SCHOOL TRANSCRIPT.

FUNDED BY THE DEPARTMENT OF THE NAVY, OFFICE OF NAVAL RESEARCH (ONR)