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Step 1 of 6 – Introduction

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Introduction
1. Introduction

How to Use This Form
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Using PDF Upload
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Records & Recommendations
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Submitting This Form
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Or, download our fillable PDF application file.

If you would rather submit this step via PDF form, please download the fillable PDF and upload below. Once you’ve uploaded a PDF, you will not be able to fill in the form unless you remove it.
Download PDF Application
Upload PDF Application
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Student Information
2. Student Information

All answers are required except where marked optional.
Personal Details
Date of Birth
MM slash DD slash YYYY
How do you identify your gender identity?
- Male
- Female
- Non-binary
- I prefer not to say
Name
First Last
Student Email
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Adult T-Shirt Size
Ethnicities (Check all that apply)
- Athabascan
- Haida
- Inupiaq
- Tlingit
- Tsimshian
- Sugpiaq
- Unangax (Aleut)
- Yup’ik/Cup’ik
- African American,Black
- American Indian
- Asian American
- Hispanic
- Native Hawaiian, Pacific Islander
- White or Caucasian
- Other
Other:
Alaska Native Regional Corporation Affiliation (Check all that apply)
- Ahtna, Inc.
- Arctic Slope Regional Corporation
- The Aleut Corp.
- Bering Straits Native Corp.
- Bristol Bay Native Corp.
- Calista Corp.
- Chugach Alaska Corp.
- Cook Inlet Region, Inc.
- Doyon, Limited
- Koniag, Inc
- NANA Regional Corp.
- Sealaska Corp.
- 13th Regional Corp.
- Not Applicable
Tribal/Village Association
Did one or more of your parent/guardians earn a 4-year college degree?
- Yes
- No
School Details
Current Grade
Expected Graduation Year
Name of School
Type of School
Education Details
Previous Math Course
Previous Math Grade
What courses are you currently enrolled in for the 2018-2019 academic year?
Math
Science
Career Path(s) Currently Interested In
Are you planning on attending the University of Alaska following graduation?
- Yes
- No
Have you ever taken a course from the University of Alaska?
- Yes
- No
University of Alaska Student ID
Look up UA Student ID
Are you a past ANSEP Pre-College Participant?
- Yes
- No
Select the program and the year you attended
- Middle School Academy
- Acceleration Academy
- STEM Career Exploration
- Other
Year Attended
Year Attended
Year Attended
Other Program Name
Year Attended

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3. Achievements & Essay
3. Achievements & Essay
If you would rather submit this step via PDF form, please download the fillable PDF and upload below. Once you’ve uploaded a PDF, you will not be able to fill in the form unless you remove it.
Download achievements & essay form
Files
Drop files here or

Max. file size: 20 MB, Max. files: 5.
List of Science and Mathematics Activities you have participated in over the last 3 years Including: school organizations, science and/or mathematics activities (science fair, math club, after school programs, summer programs, etc.) Include awards received and oﬃces held.
List any community activities and/or community groups that you have been a part of.
At the ANSEP Acceleration Academy, you will enroll in university courses. Please describe how you are prepared for this opportunity and how you will ensure your success.
In your words, tell the selection committee how you plan to contribute to the future of Alaska. This essay must be written by you, the student, and should be at least 500 words. Or, you may upload a document at the top of this page.

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Parent/Custodian Information & Consent
Parent/Custodian Information & Consent
If you would rather submit this step via PDF form, please download the fillable PDF and upload below. Once you’ve uploaded a PDF, you will not be able to fill in the form unless you remove it.
Download parent/custodian information form
Files
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Max. file size: 20 MB, Max. files: 5.
Parent #1
Name
First Last
Employer
Occupation
Daytime Phone
Home Phone
Cell Phone
Email Address
Did you complete a 4-year degree?
- Yes
- No
Add another parent?
- Yes
- No
Parent #2
Name
First Last
Employer
Occupation
Daytime Phone
Home Phone
Cell Phone
Email Address
Did you complete a 4-year degree
- Yes
- No
Number of people in household
Family yearly income level
- Under $15,000
- $15,001 – $30,000
- $30,001 – $45,000
- $45,001 – $60,000
- $60,001 – $75,000
- Over $75,000
Parental Consent
Parental Consent
I understand that as part of ANSEP’s commitment to continual improvement, ANSEP Acceleration Academy is involved in studies of the Academy and of student outcomes (“ANSEP studies”). In submittng this application, I grant permission for ANSEP to request and receive the school records of the student for whom I am submittng this application, including such information as my child’s attendance, test scores, or other academic outcomes with identiﬁable information. I further understand that this information may be used for ANSEP studies and that all student-level information will remain conﬁdential as required by the Family Educational Rights and Privacy Act (FERPA). My decision whether or not to participate in ANSEP studies will have no impact on my child’s likelihood of admission to an ANSEP Acceleration Academy. Further, there are no discernible risks to participating in ANSEP studies and while there are no direct beneﬁts to myself or my child, ANSEP and society at large may beneﬁt by better understanding what features of the Academy help students succeed.

If you have any questions about the ANSEP studies or your child’s participation, please contact Dr. Herb Schroeder at (907) 786-1860 or via email at Herb@alaska.edu
I give permission for my child to participate in ANSEP studies and I authorize his/her school, district, or state to release his/her student administrative records to ANSEP.
Parent/Guardian Signature
Date
MM slash DD slash YYYY

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Records & Recommendations
Please supply contact details for your registrar, math and science recommendations here. We will email them to request they complete the forms. Once these are received, you will be notiﬁed via email and you will be able to ﬁnalize and submit your application.
Registrar information
Files from parent(s)
Please upload the file(s) you’ve received from your parent(s).
Drop files here or

Max. file size: 8 MB.
Name
First Last
Email Address
Phone
History log
I give permission for my child to participate in ANSEP studies and I authorize his/her school, district, or state to release his/her student administrative records to ANSEP.
- Yes
- No
Parent/Guardian Signature
Date
MM slash DD slash YYYY
Science Teacher Information
Files from Science teacher
Please upload the file(s) you’ve received from your Science teacher.
Drop files here or

Max. file size: 8 MB.
Name
First Last
Email Address
Phone
History log
Math Teacher Information
Files from Math Teacher
Please upload the file(s) you’ve received from your Math teacher.
Drop files here or

Max. file size: 8 MB.
Name
First Last
Email Address
Phone
History log
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Total Files Uploaded

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Summary
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I agree to the privacy policy.
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AWARDS

Presidential Award for Excellence in Science, Mathematics, and Engineering Mentoring 2004

Top 25 Innovations in American Government 2012

Alaska Federation of Natives Denali Award 2005

U.S. Department of the Interior Partners in conservation award 2013

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Anchorage, AK 99508-4614
Fax (907) 786-1899

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