Student Information Form

Completing & Submitting the Form

All fields are required. Please read instructions carefully beneath the fields, if any. Make sure to submit the form by clicking on the “Submit Application Data” at the very end of the form. Once submitted, you will see the message, “Your responses were successfully submitted” on the screen.

Printing the Form

Please print ALL the applicant data in the email (which is all the information you entered online) and attach it to the application cover sheet of your application.

Important Note

Application packets received that have not completed the online student application information form, or are missing the printed form containing all the applicant data entered online, will be deemed incomplete, and the application will not be considered.

Student First Name *

Student Middle Name *

Enter NA if not applicable.

Student Last Name *

Student NJ SmartID *

REQUIRED for all PUBLIC school students. Enter NA if not applicable.

Street Address *

City/Town *

State *

Zip Code + 4 *

Separated by a dash. If + 4 unknown, enter 5 digit zip code only.

NJ Legislative District * 12345678910111213141516171819202122232425262728293031323334353637383940

Look up your legislative district at http://www.njleg.state.nj.us/districts/districtnumbers.asp

County * AtlanticBergenBurlingtonCamdenCape MayCumberlandEssexGloucesterHudsonHunterdonMercerMiddlesexMonmouthMorrisOceanPassaicSalemSomersetSussexUnionWarren

Student Birth Date *

Click on this field to display a calendar.

Student Email *

This is an IMPORTANT field. All correspondence from NJGSS will be sent to this email address. If none available, please enter parent/guardian or guidance counselor email.

Home Phone Number *

Please include area code. NO dashes or parentheses. Enter NA if not applicable.

Student Cell Phone Number *

Please include area code. NO dashes or parentheses. Enter NA if not applicable.

Sex *

M

F

Race/National Origin * Hispanic/LatinoAmerican Indian/Alaskan NativeAsianBlack/African AmericanNative Hawaiian/Pacific IslanderWhiteMulti-racialDeclined to Answer

Parent 1/Guardian's Title * Mr.Mrs.Ms.MissDr.

Parent 1/Guardian's First Name *

Parent 1/Guardian's Last Name *

Parent 1/Guardian's Address *

Parent 1/Guardian's City *

Parent 1/Guardian's State *

Parent 1/Guardian's Zip Code + 4 *

Separated by a dash. If + 4 unknown, enter 5 digit zip code only.

Parent 1/Guardian's Home Phone *

Please include area code. NO dashes or parentheses. Enter NA if not applicable.

Parent 1/Guardian's Cell Phone *

Please include area code. NO dashes or parentheses. Enter NA if not applicable.

Parent 1/Guardian's Email Address *

Enter NA if not applicable.

Parent 2/Guardian's Title * Mr.Mrs.Ms.MissDr.NA if not applicable

Parent 2/Guardian's First Name *

Enter NA if not applicable.

Parent 2/Guardian's Last Name *

Enter NA if not applicable.

Parent 2/Guardian's Address *

Enter NA if not applicable.

Parent 2/Guardian's City *

Enter NA if not applicable.

Parent 2/Guardian's State *

Enter NA if not applicable.

Parent 2/Guardian's Zip Code + 4 *

Separated by a dash. If + 4 unknown, enter 5 digit zip code only. Enter NA if not applicable.

Parent 2/Guardian's Home Phone *

Please include area code. NO dashes or parentheses. Enter NA if not applicable.

Parent 2/Guardian's Cell Phone *

Please include area code. NO dashes or parentheses. Enter NA if not applicable.

Parent 2/Guardian's Email Address *

Enter NA if not applicable.

School Name *

School Address *

School Town *

Please INCLUDE STATE, if NOT NJ.

School Zip Code + 4 *

Separated by a dash. If + 4 unknown, enter 5 digit zip code only .

Principal's Name *

Principal's Phone Number *

Please include area code. NO dashes or parentheses.

Principal's Email *

School Guidance Counselor's Full Name *

School Guidance Counselor's Email Address *

School Guidance Department's Phone Number *

Please include area code. NO dashes or parentheses.

School District Name *

School Type *

Public

Charter

Magnet

Private Independent

Private Parochial

Vocational/Technical

Home School

Math Teacher's Full Name *

The math teacher who is recommending the student.

Math Teacher's Email Address *

Science Teacher's Full Name *

The science teacher who is recommending the student.

Science Teacher's Email Address *

Pre-College Programs *

GEAR-UP

Johns Hopkins Center for Talented Youth

Talent Search

TARGET (The Academy at Rutgers for Girls in Engineering & Technology)

Upward Bound

Other (Identify in the next field below)

Other Programs *

Enter NA if not applicable

PSAT Test Year *

Enter NA if not applicable.

PSAT Total *

Enter NA if not applicable.

PSAT Math *

Enter NA if not applicable.

PSAT Reading and Writing *

Enter NA if not applicable.

SAT Test Year *

Enter NA if not applicable.

SAT Total *

Enter NA if not applicable.

ACT *

Enter NA if not applicable.

Email

If you are human, leave this field blank.