SummerScienceInstitute

SSI 2008 Participant Application

This application is designed to allow the SSI team to better understand you as a student. Fields marked with an asterisk(*) are required, but please complete all possible fields such that we can more fully evaluate how SSI fits into your future, and how you fit into SSI.

• Applicant Contact Information

• Name* First Last
• Address Street Address
  Address Line 2
  City
  State / Province / Region
  Postal / Zip Code
• Email*
  Phone - (###) - ### ####

• Emergency Contact Information

• Name First Last
• Relationship
• Phone - (###) - ### ####

• Family Information

• Parent/Guardian Occupation
  Parent/Guardian Highest Education Level
  Some School High School Graduate Some College 2 Yr. College Degree 4 Yr. College Degree Postgraduate Degree
• Parent/Guardian Occupation
  Parent/Guardian Highest Education Level
  Some School High School Graduate Some College 2 Yr. College Degree 4 Yr. College Degree Postgraduate Degree
• Parent/Guardian Occupation
  Parent/Guardian Highest Education Level
  Some School High School Graduate Some College 2 Yr. College Degree 4 Yr. College Degree Postgraduate Degree
• Language Commonly Spoken at Home

• Educational Information

• High School Attended*
  College/University*
• Year in School*
  Freshman Sophomore Junior Senior
• Current GPA

• Science Coursework Completed

• Biology
• Course Name Grade A A- B+ B B- C+ C C- D+ D D- F+ F School Comment
• A A- B+ B B- C+ C C- D+ D D- F+ F
  A A- B+ B B- C+ C C- D+ D D- F+ F
  A A- B+ B B- C+ C C- D+ D D- F+ F
• Chemistry
• Course Name Grade A A- B+ B B- C+ C C- D+ D D- F+ F School Comment
• A A- B+ B B- C+ C C- D+ D D- F+ F
  A A- B+ B B- C+ C C- D+ D D- F+ F
  A A- B+ B B- C+ C C- D+ D D- F+ F
• Physics
• Course Name Grade A A- B+ B B- C+ C C- D+ D D- F+ F School Comment
• A A- B+ B B- C+ C C- D+ D D- F+ F
  A A- B+ B B- C+ C C- D+ D D- F+ F
  A A- B+ B B- C+ C C- D+ D D- F+ F
• Mathematics
• Course Name Grade A A- B+ B B- C+ C C- D+ D D- F+ F School Comment
• A A- B+ B B- C+ C C- D+ D D- F+ F
  A A- B+ B B- C+ C C- D+ D D- F+ F
  A A- B+ B B- C+ C C- D+ D D- F+ F

• Narrative Information

• What health professions or science career are you most interested in?*
• What are your strengths in the sciences? Your weaknesses?*
• What are your goals in science or healthcare?*
• What exposure have you had to the health professions?*
• What do you hope to get out of SSI?*
• How did you hear about SSI?*

• Financial Information

• Will you be working during the summer of 2008?*
  Will you be taking classes during the summer of 2008?*
  Are you currently receiving financial aid?*
  Will you need assistance with housing during the summer of 2008?*