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.
* Required
Email address
*
Your email
Student's Last Name (Apellido del estudiante)
*
Your answer
Student's Middle Name (Segundo nombre del estudiante)
*
Your answer
Student's First Name (Primer nombre del estudiante)
*
Your answer
Date of Birth (Fecha de nacimiento)
*
MM
/
DD
/
YYYY
Gender (Sexo)
*
Female
Male
Other:
Race/Ethnicity (Raza)
*
Choose
African-American/Black
Asian
Bi-Racial
Caucasian
Native American
Hispanic/Latino
Pacific Islander
Other
Home Address (Dirección particular)
*
Your answer
City (Ciudad)
*
Your answer
Zip Code (Código postal)
*
Your answer
Home Phone Number (Número de teléfono de casa)
*
(Please use this format: (area code) xxx-xxxx)
Your answer
Student's Cell Number (Número de celular del estudiante)
(Please use this format: (area code) xxx-xxxx)
Your answer
Student's Email Address (Dirección de correo electrónico del estudiante)
Your answer
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.
Yes
No
Career Interest (Interés profesional)
*
Choose
Computer Science/programming
Education/Teaching (Elementary, Middle, or High School)
Engineering
Mathematics/Statistics
Medicine (doctor, dentist, nursing, physical therapy, etc)
Natural Science (biology, botany, genetics, horticulture, marine biology, zoology)
Physical Science (chemistry, geology, meteorology, physics)
Other (please fill out your field of interest at the end of the form under "Other")
Psychology
Technology (drones, robotics, etc.)
Undecided
Number of previous years in MSEN (Números de años anteriores en MSEN)
*
Choose
0
1
2
3
4
5
6
Next
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