SECTION I. To be completed by student. (Please print)
_____________________________________________________________________________________________
Applicant Name (first, middle, last): *Sex: *Birth date & year
_____________________________________________________________________________________________
Home Phone Number:
Mailing Address:
_______________________________________________________________________________________________
City and Zip Code: County:
_______________________________________________________________________________________________
School Now Attending: Current Grade Level:
__________________________________________________________________________________
____________
School Address: School’s County
_______________________________________________________________________________________________
Number of students in your high school: Number of students in your current
grade:
_______________________________________________________________________________________________
*Race or Ethnic Group: Nationality: Applicant lives with: Check, if applicable:
___American Indian US Citizen: ___Both Parents ___Mother deceased
___Asian Yes ___ ___Mother ___Father deceased
___Black No ___ ___Father ___Parents divorced/
___Hispanic If no, please explain: ___Stepparent separated
___White ___Other (specify):
___Other
_______________________________________________________________________________________________
Parent/Guardian Name:
Daytime Work Phone Number:
_______________________________________________________________________________________________
Parent/Guardian Address (if different from above):
_______________________________________________________________________________________________
List names and ages of your brothers and sisters:
_______________________________________________________________________________________________
SECTION II. To be completed by student and parent(s)/guardian.
_______________________________________________________________________________________________
*Does applicant have a handicap or health condition that requires special
attention? Yes No
If yes, please explain:
*Equal Opportunity Information: OSSM does not discriminate based on race,
sex, creed, national origin, age or handicap. The purpose of gathering this
information is to ascertain the effectiveness of recruitment efforts and to
ensure that proper facilities are available to serve all students selected
for admission.
____________________________________________
_______________________________________
Founded 1990 for the People of Oklahoma
SECTION III. To be completed by student and parent(s)/guardian.
The information contained herein is true and accurate. If the applicant is
accepted for admission to The Oklahoma School of Science and Mathematics,
Indian Capital Technology Regional Centers we agree to adhere to the rules
and regulations of OSSM. We also agree to permit the information within this
application and in other records used to apply to OSSM to be made available
on a confidential basis to the student’s home school, other educational
institutions, and for other purposes pursuant to the Family Educational Rights
and Privacy Act of 1974, as amended, and applicable regulations. / /
Parent/Guardian Signature Date Applicant Signature Date Release of Confidential
Information
We, the parents/guardian of the applicant, hereby consent to the release of
this application to The Oklahoma School of Science and Mathematics; Indian
Capital Technology Regional Centers review committee. We understand that the
review committee is designed to ensure fair representation of students from
across Oklahoma. The review committees’ specific purpose is to review
all applications of prospective students so as to recommend students best
qualified to attend the school. We understand further that this release to
the review committee will not allow any other person not otherwise privileged
to review this application to have access to it.
We understand that a decision not to sign this release will not affect consideration
by the school of our child’s application. By our signatures below, we
indicate that we have read this release, understand it, and agree to the terms
contained in it.
/ /
Father’s Signature:
Date:
Mother’s Signature:
Date:
(Both natural parents are required to sign this release unless parental rights
have been terminated by court order or in the event of the death of a parent.)
Recommendations/Standardized Test Information
Names of individuals completing your recommendation forms and their schools:
Mathematics teacher:____________________ School: ______________________________
Science teacher:_______________________ School: _______________________________
Counselor: ___________________________School: _______________________________
When did you (or will you) take the ACT? ________________________
(If you still must take the ACT, see page 7 of instructions for information
on additional materials/test scores to be submitted.)
SECTION IV. APPLICANT ESSAYS To be completed by student. (Please print in
ink)
1. When you are not attending school, working on school assignments, doing
chores at home, or earning money, what do you like to do? Of the things that
you do during your spare time which do you like the best and why?
2. What math and science activities, both in school and out, have you been
involved in during the past two years?
3. Please describe a stressful situation in your life, how you coped with it, and what you learned from the situation.
4. Describe a situation from your experience that required you to make an
ethical decision concerning your behavior.
5. What are your career plans and how will The Indian Capital Technology Regional
Centers of the Oklahoma School of Science and Mathematics help facilitate
your attainment of these future professional goals?
SECTION V. To be completed by parent(s)/guardian. (Please print in ink)
Please tell us how you feel The Oklahoma School of Science and Mathematics,
Indian Capital Technology Regional Centers will help enhance and promote your
child’s future professional goals. Do not use your child’s last
name, school or town in your comments. Identify yourself as “mother”,
“father” or “guardian”. Please do not sign your name.
