Minority Faculty Development Program 164 Longwood Avenue, 2nd Floor Boston, Massachusetts 02115-5810 P 617-432-4634 F 617-432-3834 www.mfdp.med.harvard.edu

PROJECT SUCCESS: OPENING THE DOOR TO BIOMEDICAL CAREERS 2015 NEW HIGH SCHOOL STUDENT - Application Form DEADLINE FOR RECEIPT OF COMPLETE APPLICATION: Friday, February 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 9th grade. All application materials must be in our office by 5pm on Friday, February 6, 2015. The high school program is eight (8) weeks, from June 25, 2015- August 14, 2015. 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 Harvard Medical School 164 Longwood Avenue, 2nd Floor Boston, MA 02115-5818 Tel: 617-432-4634 Fax: 617-432-3834

Program Dates: June 25 – August 14, 2015

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 #_________________Email ____________________________

4.

Date of Birth (M/D/YY)

5.

Age you will be on June 25, 2015______________________________________

6.

Current High School ______________________________Guidance Counselor Name & telephone number:________________________________________________________________________________

7.

Current School Grade (check one)

Senior ____

Expected Year of High School Graduation

Junior ____

2015 ____

2016 ____

****** 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.

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Family Information-Parent/Guardian 8.

Parent/Guardian 1 (Name) _______________________________________________________________________

9.

Street Address _____________________________ City_________________ Zip _______________

10.

Home Phone (

12.

Email ______________________________________________________________

13.

Parent/Guardian 2 (Name) _______________________________________________________________________

14.

Street Address _____________________________ City_________________ Zip _______________

15.

Home Phone (

16.

Email _____________________________________________________________

) ___________________________ 11. Work/Cell Phone (

) ___________________________ 11. Work/Cell Phone (

) ___________________________

) ___________________________

17. How did you hear about the Project Success program? (check all that apply) __ __ __ __ __ __ __ __

a. b. c. d. e. f. g. h.

high school guidance counselor former Project Success participant bulletin board HPREP high school science teacher Harvard Medical School faculty member, physician or administrator Biomedical Science Careers Program (BSCP) 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

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

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

___

___

Don’t Know

Program Name/Date

______________________________

23. Have you taken any of the following examinations? (please check all that apply) Yes

No

Verbal Score

Math Score

Total Score

Date

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? _______________________________________________________________________________________________ ________________________________________________________________________________________________

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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.

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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

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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

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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

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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.

Superior Leadership Maturity/Judgment Dependability/reliability Character/integrity Imagination/creativity Initiative Perseverance

___ ___ ___ ___ ___ ___ ___

Very Good ___ ___ ___ ___ ___ ___ ___

Good

Fair

Poor

N/A

___ ___ ___ ___ ___ ___ ___

___ ___ ___ ___ ___ ___ ___

___ ___ ___ ___ ___ ___ ___

___ ___ ___ ___ ___ ___ ___

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

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