Apply to the MESA Schools Program

General Info
Returning MESA Student?:
*Last Name:	*First Name:
Middle Initial:	*Birth Date:YYYY-MM-DD
Student ID at School District:	*School Year:
*Permanent Address:	*City:
*State:	*Zip:
*Email:
*Home Phone: xxx-xxx-xxxx	*Gender:
*Parent/Guardian Name:	Work Phone: xxx-xxx-xxxx
Parent/Guardian Name:	Work Phone:
*Ethnicity:	Ethnicity (Other):
If American Indian, plese specify Tribal Affiliation:	*Primary Language Spoken in Home:
*School Name:	*Grade:

What Programs did you Participate in Last Summer?

Check all that apply
MESA Summer Program
Other Summer School Program
Special Summer Activity
Summer Job
Other Summer Program:

Check all that apply
Puente
UC Early Academic Outreach
CSU Early Outreach
Upward Bound
AVID

Career & Education
*Primary Career Interest:
*Highest level of education achieved by your father/guardian:	*Type of work typically done by father/guardian:
*Highest level of education achieved by your mother/guardian:	*Type of work typically done by mother/guardian:

Current Courses
What math courses are you currently enrolled in?:
What science courses are you currently enrolled in?:
What English courses are you currently enrolled in?:
What computer courses are you currently enrolled in?:

Course Information
Period 0 Course:	Period 0 Teacher:	Period 0 Room:
Period 1 Course:	Period 1 Teacher:	Period 1 Room:
Period 2 Course:	Period 2 Teacher:	Period 2 Room:
Period 3 Course:	Period 3 Teacher:	Period 3 Room:
Period 4 Course:	Period 4 Teacher:	Period 4 Room:
Period 5 Course:	Period 5 Teacher:	Period 5 Room:
Period 6 Course:	Period 6 Teacher:	Period 6 Room:
Period 7 Course:	Period 7 Teacher:	Period 7 Room:
Period 8 Course:	Period 8 Teacher:	Period 8 Room:
Period 9 Course:	Period 9 Teacher:	Period 9 Room:

Home Room Info
Home Room:	Home Room Teacher:

Need Signature Form to Complete Application
Your application is not confirmed until the Signature form has been completed. The completed original Signature form can either be faxed to number 805.756.1434 or mailed to: Attn: R. David Cantu MESA Center California Polytechnic State University 1 Grand Avenue San Luis Obispo, CA 93407-0206 Signature Form (English) Signature Form (Espanol)

Parent/Guardian Signature: ___________________________________________