PROJECT SUCCESS: OPENING THE DOOR TO BIOMEDICAL CAREERS 2015 NEW HIGH SCHOOL STUDENT - Application Form

Transcription

1 Minority Faculty Development Program 164 Longwood Avenue, 2 nd Floor Boston, Massachusetts P F PROJECT SUCCESS: OPENING THE DOOR TO BIOMEDICAL CAREERS 2015 NEW HIGH SCHOOL STUDENT - Application Form DEADLINE FOR RECEIPT OF COMPLETE APPLICATION: Friday, Februar y 6, 2015 by 5:00PM To be eligible to participate in Project Success 2015, you must reside in Boston or Cambridge, Massachusetts, currently in grade 11 or 12 with a minimum 2.70 Grade Point Average (GPA), at least 16 years of age by June 25, 2015, and have completed algebra, biology and chemistry. You must be able to provide documentation that you are allowed to work. Also include with your application your high school transcripts beginning with 9 th grade. All application materials must be in our office by 5pm on Friday, February 6, The high school program is eight (8) weeks, from June 25, August 14, You must be able to commit to the entire eight weeks. Please complete and return your complete application to: Sheila Nutt, EdD Minority Faculty Development Program Project Success Program Dates: June 25 August 14, 2015 Harvard Medical School 164 Longwood Avenue, 2 nd Floor Boston, MA Tel: Fax: PART I. (Please print in blue or black ink or type in the following information) Student Information 1. Name 2. Home Street Address City Zip 3. Home Telephone cell # 4. Date of Birth (M/D/YY) 5. Age you will be on June 25, Current High School Guidance Counselor Name & telephone number: 7. Current School Grade (check one) Senior Junior Expected Year of High School Graduation ****** If you do not have a Social Security Number, or a visa that allows you to work, or are not able to provide proof that you are authorized to work, you will not be able to participate in the program. Participants are paid to work in the research sites; we are not allowed to accept volunteers. If you are admitted to the program, please be prepared to submit this documentation. 1

2 Family Information-Parent/Guardian 8. Parent/Guardian 1 (Name) 9. Street Address City Zip 10. Home Phone ( ) 11. Work/Cell Phone ( ) Parent/Guardian 2 (Name) 14. Street Address City Zip 15. Home Phone ( ) 11. Work/Cell Phone ( ) How did you hear about the Project Success program? (check all that apply) a. high school guidance counselor b. former Project Success participant c. bulletin board d. HPREP e. high school science teacher f. Harvard Medical School faculty member, physician or administrator g. Biomedical Science Careers Program (BSCP) h. Other PART II. 18. Please list any honors, awards or special recognitions, you have received. 19. Briefly describe any of your past or present extracurricular activities, especially those related to science and/or health. 20. Briefly describe any special interests you may have. 21. List any community or national organizations to which you belong. 2

3 22. Have you ever participated in any of the following types of science programs? (Please check the appropriate line for each type of program. If yes, please provide the program name.) Yes No Don t Know Program Name/Date a. non-high school sponsored science education program b. science research c. career educational planning d. science mentoring e. AP Biology Hinton Scholars f. Explorations g. Biomedical Science Careers Program h. HPREP 23. Have you taken any of the following examinations? (please check all that apply) Yes No Verbal Math Total Date Score Score Score a. PSAT b. SAT c. ACT 24. What is your current high school grade point average (GPA)? (See your Guidance Counselor) PART III. 25. Please include a copy of your most recent school transcript with your application. PART IV. 26. Will you attend college after you graduate from high school? (please check one) Yes No Undecided Are you the first in your family to attend college? Yes No Has your mother attended college? Yes No Has your father attended college? Yes No If Yes: What colleges or universities are you considering? What would you like to study? 3

4 If No: If you are not planning to attend college after high school, what will you do after graduation? 27. What do you see yourself doing in two (2) years? 28. What do you see yourself doing in ten (10) years? 29. Briefly describe what you would like to gain from your participation in the Project Success high school program? 30. Have you ever been discouraged from pursuing one of the following: (Please check the appropriate line for each type of program) Yes No Don t Know a. College-Level Studies b. Career in Science or Engineering 31. Describe three (3) talents and/or skills that you feel have made you successful in your academic career. 4

5 PART V. Please answer the following optional questions: 32. Please indicate your predominant ethnic background: Asian Chinese Filipino East Indian Japanese Korean Vietnamese Other (specify) Black (not Hispanic/Latino) African-American African (specify) Caribbean (specify) Other (specify) Hispanic/Latino Cuban Dominicam Mexican/Mexican American Puerto Rican South or Central American (specify) Other (specify) American Indian/Alaska Native Tribal Affiliation Native Hawaiian/ Other Pacific Islander White (not Hispanic/Latino) Other (specify) Unknown 33. Do you receive free or reduced rate meals at school? Yes No DEADLINE FOR RECEIPT OF APPLICATION: FRIDAY, FEBRUARY 6, 2015 by 5:00PM 5

6 Name (please print) School PART VI. APPLICATION FORM STUDENT STATEMENT OF INTEREST Project Success 2015 New Student Application A statement of interest is required for your application. Use this form to describe yourself as a student, your interest in the biomedical field, and why you should be considered for participation in Project Success. (Please print or type.) You may use an additional page. Signature of Student/Applicant Date Printed Name of Student/Applicant Date DEADLINE FOR RECEIPT OF APPLICATION: Friday, February 6, 2015 by 5:00PM 6

7 Name (please print) School PART VII. CONSENT ( Parent or Guardian) In signing this form, I certify that this application has been read and that the information is correct to the best of my/our knowledge. I have reviewed the 2015 Project Success Announcement, and I consent for my son or daughter to participate in the Project Success Program if he/she is selected. I further understand that the selection is the responsibility of the program. Additionally, I give consent for my child to use public or private transportation for participation in program related activities and to receive routine and/or emergency medical service (if necessary). I authorize the program to use still or video photographs of my child for publicity purposes. Print Name: Sign Name: Date: Student Contract: I am willing to abide by the conditions and regulations set forth by the Project Success Program. I realize that failure to comply with these rules may result in dismissal from the program. Print Name Signature of Student Date Parent/Guardian please read and sign below. I am willing to have my child abide by the conditions and regulations set forth by the Project Success Program Print Name Signature of Parent/Guardian Date DEADLINE FOR RECEIPT OF APPLICATION: FRIDAY, FEBRUARY 6, 2015 by 5:00PM 7

8 Name (please print) School PART VIII LETTER OF RECOMMENDATION Project Success 2015 Student Application Recommendation from your science teacher is required for your application. You, the applicant, should complete the first portion of this form and then give it to your science teacher to complete. The letter of recommendation should be included in the completed application package. In order to ensure the recommendation be kept confidential, have your science teacher return this letter to you in a signed, sealed envelope. TO BE COMPLETED BY THE STUDENT/APPLICANT Name of Student/Applicant: Name of School: TO BE COMPLETED BY THE SCIENCE TEACHER Please put an X on the appropriate line that you believe most accurately describes this student applicant. Very Superior Good Good Fair Poor N/A Leadership Maturity/Judgment Dependability/reliability Character/integrity Imagination/creativity Initiative Perseverance Please add any comments or describe any additional qualities or characteristics of this applicant that you feel would be helpful to the Project Success Selection Committee in evaluating this applicant. We sincerely appreciate your thoughtful evaluation of this student. Signature of Science Teacher How long have you known this student? Printed Name of Science Teacher Date DEADLINE FOR RECEIPT OF ALL APPLICATION MATERIALS: FRIDAY, FEBRUARY 6, 2015 by 5:00PM 8