Jump Start Program Application For more information, visit the Jump Start online. * - Required field Student Information First Name:* Last Name:* NMU IN: E-mail:* Street Address:* City: State: Alabama Alaska American Samoa Arizona Arkansas Baker Island California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Howland Island Idaho Illinois Indiana Iowa Jarvis Island Johnston Atoll Kansas Kentucky Kingman Reef Louisiana Maine Maryland Massachusetts Michigan Midway Islands Minnesota Missouri Mississippi Montana Navassa Island Nebraska Nevada New Jersey New Hampshire New York New Mexico Northern Mariana Islands North Dakota North Carolina Ohio Oklahoma Oregon Palmyra Atoll Pennsylvania Petrel Islands Puerto Rico Rhode Island Serranilla Bank South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Wake Island Washington West Virginia Wisconsin Wyoming Zip: Phone Number:* - - Demographic African American / Black Caucasian / White Hispanic / Latino(a) Multiracial Asian or Pacific Islander Native American Prefer not to respond Parent Information First Name: Last Name: Contact Phone: - - E-mail: Educational Interests Intended Major:* Intended Minor: (if any) Extracurricular Interests: Types of activities you could see yourself involved in, e.g. sports, clubs, sororities, or fraternities. Statement of Understanding By entering my initials in the box below: I will abide by the requirements of participation in the Jump Start program. I understand that participation is voluntary, and that I can withdraw from the program at any time. I understand that by withdrawing from the program that I lose all privileges and benefits associated with the program. I understand that the information provided on this form will be used to for the sole purpose of entrance into the Jump Start program and assignment to a Jump Start Team. Signature:* Questions? E-mail the Web master, or call the MERC Office at 906-227-1554.