Attention Sophomore & Junior High School Students Interested in the Sciences You Are Cordially Invited To Attend the

Transcription

1 Attention Sophomore & Junior High School Students Interested in the Sciences You Are Cordially Invited To Attend the Friday, April 16 th (6:00pm) Saturday, April 17 th (3:00pm) We have planned an exciting weekend of programs in which you will gain a true sense of what it is like to be a student at the Ernest Mario School of Pharmacy at Rutgers University! Spend the night on campus! Join us for activities, bowling, and a hands-on lab experience with other high school students from all over New Jersey! Please complete and return or fax the application & permission slip to: Melissa Vargas Columna Office for Student Development Ernest Mario School of Pharmacy Rutgers University 160 Frelinghuysen Road Piscataway, NJ Fax # (732) ****Application Deadline: MARCH 19, 2010**** If you have any questions, please contact Ms. Melissa Vargas Columna at (732) ext. 628 or mvargas@rci.rutgers.edu Note: You must provide your own transportation to and from event. Your guidance counselor will be notified of your acceptance by April 9, 2010.

2 Office for Student Development/Educational Opportunity Fund Program NOTE: APPLICATIONS & PERMISSION SLIPS MUST BE RECEIVED BY: FRIDAY, MARCH 19, MATERIALS RECEIVED AFTER THIS DEADLINE MAY NOT BE CONSIDERED. Personal Information <<<<<<Please Print or Type All Information>>>>>> Name: _ SS# - - Date of Birth (Month/Date/Year) / / Gender Home Address _ City State Zip Code Home Telephone Number ( ) Address High School Address _ City State Zip Code High School Telephone # Guidance Counselor Anticipated Graduation Date Current Overall GPA (Required) Career Interest Family Information Father s/legal Guardian s Last Name First Name Living Deceased Occupation Father s highest level of formal education Address (If different from yours City State

3 Home Telephone Number ( ) Business Telephone Number ( ) Mother s/legal Guardian s Last Name First Name _ Living Deceased Address (if different from yours) _ City State Occupation Mother s highest level of formal education Home Telephone Number ( ) _ Business Telephone Number ( ) Short Essay Section What are your plans after high school? How do you feel you would benefit from participating in the Overnight Experience? Would you be interested in attending a 5-week Pharmacy Summer Enrichment Program? YES NO

4 PLEASE RETURN THIS APPLICATION AND ALL SUPPORTING MATERIALS REQUESTED TO: Melissa Vargas Columna Senior Counselor of Special Programs Office for Student Development/Educational Opportunity Fund Program Ernest Mario School of Pharmacy Rutgers University 160 Frelinghuysen Road Piscataway, NJ Applications & Supporting Materials may also be faxed to: (732) Please feel free to contact Ms. Columna at (732) Ext. 628, should you have any further questions. My signature indicates that this application, including supporting materials, is complete, factually correct and honestly prepared. _ Student s Signature Parent s Signature Date FOR OFFICE USE ONLY COMMENTS:

5 Office for Student Development/Educational Opportunity Fund Program Permission Slip for Participation in the Please Note: Failure to submit this slip will forfeit your potential selection for this event. I (We), the parent(s), or guardian(s) of (name of student), this day of, 2010, willingly grant permission for the aforementioned minor to participate in the Ernest Mario School of Program beginning on Friday, April 16, 2010 (6:00pm) and ending on Saturday, April 17, 2010 (3:00pm). I further understand that it is my responsibility to transport my child to and from this activity and to arrive promptly at the specified times. I endorse that my child acknowledges this event and wishes to participate in lieu of its focus on the science - particularly pharmacy. I (We) further, forever release, acquit, and discharge the Ernest Mario School of Pharmacy and any volunteers affiliated with this event, from any and all liabilities, claims, and causes of actions that I or we may have by reason of said participation. Parent/Guardian Signature Student Signature Date

6 MEDICAL QUESTIONNAIRE NAME : S.S. # EMERGENCY CONTACT PERSON: EMERGENCY CONTACT PERSON #: Do you have any medical problems that we, Ernest Mario School of Pharmacy, should be aware of in case of an emergency? NO YES Do you have any food allergies? NO YES If you marked yes, please explain below: SIGNATURE OF STUDENT: SIGNATURE OF PARENT: (If student is under 18 years)

7 Office for Student Development/Educational Opportunity Fund Program Guidance Counselor Recommendation Form 1. Does the student have any special needs or require accommodations that you are aware of? Yes No If yes, please explain: 2. To your knowledge, is this student truly interested in the Pharmacy Program? Yes No 3. Do you have any reservations about this student participating in our program? Yes No If yes, please explain: Guidance Counselor Name Signature Phone Number/Extension Date