KAPI‘OLANI COMMUNITY COLLEGE
STEM: SCIENCE, TECHNOLOGY, ENGINEERING, MATHEMATICS
Mrs. Keolani Noa STEM Outreach Coordinator: Roots, Resilience, and Reach, and NSF supported initiative
4303 Diamond Head Road, Honolulu, HI 96816
Email:keolani@hawaii.edu Phone: (808) 734-9236,
Web: http://stem.kcc.hawaii.edu v. 11/2/12
UNIVERSITY OF HAWAI‘I SYSTEM
Date: _______________________
Student’s Name: ___________________________ UH Student ID#:______________________
U.S. Citizen: Yes No Gender: Date of Birth:__________________
Current Street Address: ________________________________________________________________
City: ______________________ State: ______________ Zip Code: ________________
Telephone: ______________________ Secondary Phone: _______________________
UH Email: ___________________@hawaii.edu Secondary Email: _______________________
Current Year in College: Freshman Sophomore Junior Senior
Previously/Currently taking classes at (check all that apply):
University of Hawai‘i: Manoa Hilo Hawai‘i CC
Honolulu CC Kapi‘olani CC Kaua‘i CC
Leeward CC Maui CC Windward CC
Other: ____________________________
Major: ___________________ Minor: ____________________
ASNS degree major: No Life Science Physical Science Pre-Engineering
Check all that apply:
Native Hawaiian/Part-Hawaiian/Mixed Hawaiian Samoan Tongan
Guamanian or Chamorro Micronesian Other Pacific Islander
African American or Black Latino/Hispanic Filipino Caucasian
American Indian/Alaskan Native Asian Indian Chinese Japanese
Korean Laotian Thai Vietnamese
Other Asian Other: __________________________
Student’s Signature: _______________________________________________________
Office use only:___________________________________________________________
TCUP Mentor: _____ NASA / Space Grant: _____
TCUP Student Project: _____ INBRE: _____
Kokua/Tutor: _____ Internship: _____
Kako’o/Student Help: _____ Research: _____
Summer Bridge: _____ START-UP: _____
*Please print, sign, and submit this form to Mrs. Keolani Noa (keolani@hawaii.edu)
