2020-2021 NC-MSEN Pre-College Program Registration Form
The ECSU NC-MSEN Pre-College Program provides STEM enrichment and college preparation for under-served students in grades 6-12 in Northeastern North Carolina.

A registration fee of $50 per student is required to participate for the 2020-2021 academic year.

Incomplete applications packet may prevent students from being selected.This form should be completed by ALL students participating in ECSU NC-MSEN Pre-College Program for the 2020-2021 school year.
Email address *
Student's Last Name (Apellido del estudiante) *
Student's Middle Name (Segundo nombre del estudiante) *
Student's First Name (Primer nombre del estudiante) *
Date of Birth (Fecha de nacimiento) *
MM
/
DD
/
YYYY
Gender (Sexo) *
Race/Ethnicity (Raza) *
Home Address (Dirección particular) *
City (Ciudad) *
Zip Code (Código postal) *
Home Phone Number (Número de teléfono de casa) *
(Please use this format: (area code) xxx-xxxx)
Student's Cell Number (Número de celular del estudiante)
(Please use this format: (area code) xxx-xxxx)
Student's Email Address (Dirección de correo electrónico del estudiante)
Free/Reduced Lunch Status (Estado del almuerzo gratis/o con descuento) *
Does the student qualify for free/reduced lunch? Documentation must be provided to the MSEN Office at ECSU.
Career Interest (Interés profesional) *
Number of previous years in MSEN (Números de años anteriores en MSEN) *
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