2021

-2022
ALBANY MEDICAL
COLLEGE SCIENCE
AND TECHNOLOGY
ENTRY PROGRAM
Application Form
A New York State Education Department Funded Program

***Important, Please Note***

This is a SHORT Application Form. A complete version of the application will be required after enrollment.
We will need additional responses for reporting to New York State Education Department (NYSED).

Place Current Student Head

Shot Photo
Ins Here

Ms. Marva Richards, MPH

Albany Medical College
2021-2022
 AMC STEP Application
Full Name: Date:
Last First M.I.

Address:
Street Address Apartment/Unit #

City State ZIP Code

Student Email: ___________________________ Parent Email: __________________________________________

Parent/Guardian phone: ____________________________ Student Phone: ________________________________

Gender: ___________ School Name: ___________________________________ Grade in September: __________

NY State Resident: Yes [ ] No [ ] Place of Birth (City/Town/Country):_________________________

U.S. Citizen: Yes [ ] No [ ]

Permanent Resident: Yes [ ] No [ ] Date: ___________________

Eligible for Free/Reduced School lunch: Yes [ ] No: [ ]

Ethnicity: (Please Check) Required (**)

[ ] African American/Black** [ ] Hispanic/Chicano/Latinx (please specify)**

[ ] American Indian/Alaskan Native** [ ] Other (please specify)**

*Includes students from Africa and the Caribbean.

**If you checked “other”, please refer to Appendix Guidelines for Student Eligibility to determine if you
are eligible based on low socio-economic status. If you are not an under-represented minority and
do not provide financial documentation as required by New York State, your application will not be
considered.

Student Agreement:

I, (Student Name) ________________________________ agree to participate in the Science and Technology Entry
Program (STEP) at Albany Medical College as scheduled, and will diligently try to be present, respectful, and on
time for my sessions. I understand that my signature on this document constitutes an agreement between me and
Albany Medical College.

Student Signature: _____________________________ Date: __________________________

Parent Agreement:

I, (Name of Parent/Guardian) ______________________ give permission for (Student Name) ____________________

to participate in the Science and Technology Entry Program (STEP) at Albany Medical College and attend all
scheduled sessions.

Parent/Guardian Signature: _____________________________ Date: __________________________

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 SCIENCE AND TECHNOLOGY ENTRY PROGRAM RELEASE FORM

1. GRADES/NYSSID #/TRANSCRIPTS 2. Photo

One

I, __________________________ (student name), a participant in the Science and Technology Entry Program,
agree to the release my NYSSID number to the program for the purpose of providing academic services and
for academic assessment, program evaluation and reporting to NYSED.

__________________________________ _________________________________
Student Signature Parent/Guardian Signature

Two

I also agree to the release of photographic images taken at STEP activities to be used for STEP program
promotion.

________________________________ ________________________________
Student Signature Parent/Guardian Signature

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