B2-CARS Middle School Student Application Form 1 Start 2 Complete Student Name * First First Last Last Phone Number * Email * Permanent Address * Country * - None -United States Address 1 * Address 2 City * State * - None -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--Armed Forces (Americas)Armed Forces (Europe, Canada, Middle East, Africa)Armed Forces (Pacific)American SamoaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoVirgin Islands ZIP code * What grade will you be in when the school year starts (August 2025)? * 7th grade 8th grade Returning What is your gender? * Female Male Prefer not to say Other What is your ethnicity? (Select all that may apply) * Asian American or Pacific Islander Black or African American Hispanic or Latino Native American White or Caucasian Prefer not to say Other Rank: Strongly disagree, disagree, agree or strongly agree * Strongly disagreeDisagreeAgreeStrongly agree Learning science is interesting * Learning science is interesting - Strongly disagree Learning science is interesting - Disagree Learning science is interesting - Agree Learning science is interesting - Strongly agree Learning science will help me get a job * Learning science will help me get a job - Strongly disagree Learning science will help me get a job - Disagree Learning science will help me get a job - Agree Learning science will help me get a job - Strongly agree I spend a lot of time learning science * I spend a lot of time learning science - Strongly disagree I spend a lot of time learning science - Disagree I spend a lot of time learning science - Agree I spend a lot of time learning science - Strongly agree Knowing science will benefit me in my future * Knowing science will benefit me in my future - Strongly disagree Knowing science will benefit me in my future - Disagree Knowing science will benefit me in my future - Agree Knowing science will benefit me in my future - Strongly agree My favorite subject is math * My favorite subject is math - Strongly disagree My favorite subject is math - Disagree My favorite subject is math - Agree My favorite subject is math - Strongly agree My favorite subject is science * My favorite subject is science - Strongly disagree My favorite subject is science - Disagree My favorite subject is science - Agree My favorite subject is science - Strongly agree Does your future career involve science, technology, engineering and/or math? * Yes No Undecided or unsure After high school, do you plan to attend college? * Yes No Undecided or unsure In college, do you plan to pursue science, technology, engineering or math as a major? * Yes No Undecided or unsure What career do you want to have when you grow up and why? * What is your t-shirt size? (adult sizes) * small medium large Xlarge XXlarge Other *Please send letter of recommendation from a teacher (past or present) or mentor describing your academic work ethic and interest in science (optional). Email letter to: csudler [at] desu.edu Subject: Applicant Name_Recommendation Questions for parent/guardian only: _____________________________________________ Parent/Guardian Name * First First Last Last Parent/Guardian Phone Number * Parent/Guardian Email * Parent/Guardian Permanent Address * Country * - None -United States Address 1 * Address 2 City * State * - None -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--Armed Forces (Americas)Armed Forces (Europe, Canada, Middle East, Africa)Armed Forces (Pacific)American SamoaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoVirgin Islands ZIP code * How would you describe your student’s academic motivation and achievement? What do you feel is your role in your child’s education? In which Cohort would you prefer your child/children to participate? * 7/1/2024 -7/26/2024 Do you have access to internet? * Yes No Which social media platform(s) do you allow your child/children to utilize? Select all that apply. * Facebook TikTok Instagram Twitter Snapchat Other I do not allow my child/children to use social media What is the total number of individuals living in the household? * What is your total household income? * Less than $10,000 $10,000 to $19,999 $20,000 to $29,999 $30,000 to $39,999 $40,000 to $49,999 $50,000 to $59,999 $60,000 to $69,999 $70,000 to $79,999 $80,000 and above Prefer not to say What is the highest degree or level of education you have completed? * No Diploma GED High School Diploma Associate's Degree Bachelor's Degree Master's Degree Doctorate Degree Professional Degree Prefer not to say Other What is your current employment status? * Employed Full-Time Employed Part-Time Seeking opportunities Retired Prefer not to say Parent/Guardian Consent Statement * If selected, I will allow and support my child in participating in the two-week summer camp and six science community meetings during the academic year. By typing my name below, I give consent for my child to apply to this program.
