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2017 NCIA/MATC Sovereign Native Youth STEM Leadership Academy - Application Form


Deadline: Thursday, June 15, 2017



You must complete the online application in one sitting. Make sure to have all the required information ready. Progress cannot be saved.

* Required

All information provided will remain confidential.


First name: *
Middle name:
Last name: *
Home address: *
Apartment/unit:
City: *
State: *
Zip: *
Home phone: *
Cell phone:
Email: *
Emergency contact: *
   Phone: *
   Alt. Phone:*
Alt. Emergency contact: *
   Phone: *
   Alt. Phone:*
Tribal affliation: *
Enrollment number: *
Shirt size (polo): *
Shirt size (t-shirt): *
Gender: *
Age: *


In order to accommodate the needs of our participants and make necessary preparations in advance, the following information must be provided. The information provided in response to the three prompts below will not be considered in the evaluation of applicants.

Dietary restrictions/Food allergies (if any): *

Please detail any medical issues or medications that we should be aware of: *

Participation in the program requires moderate exercise, such as daily walking to and from activity sites, bowling, and potentially hiking. We welcome applicants of all abilities, so please indicate below if accommodations are needed to participate in these activities. *

Grade level entering in the fall: *

Current GPA: *

What is your interest in science? *

What is your interest in mathematics? *



What are your plans after graduating high school?* (100 words or less)

What are your unique leadership qualities?* (50 words or less)

We are looking for Native youth who represent each of the categories below. Which area best
describes you?*
Already an established leader
Becoming a leader (have had some experiences)
Could be a leader (shows interest but needs skill and opportunity)

List the school or non-school related leadership activities you have been involved with from
9th grade to the present*

What do you feel is the most challenging issue facing young people in your community today?*
(500 words or less)

What do you associate with the term “transportation”?* (100 words or less)


Note:If you are facing any technical difficulties with this application, please contact Karthik

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