2015 UMKC Summer Scholars Program

2015 UMKC Summer Scholars Program
Application
INSTRUCTIONS: PLEASE COMPLETE THIS FORM IN INK OR TYPE
Name: __________________________________________________________________
Address: ________________________________________________________________
City/State: ________________________________________ Zip Code______________
Phone No.: (___)_______________________
Male:_____ Female:_____
Grade in School as of Sept. 2015:____________________
EMAIL ADDRESS:_______________________________________________________
(Required--will be used to notify you of the decision)
High School Attended:_____________________________________________________
Parents
name(s)______________________________________________________
____
Address ____________________________________________(if
different than above)
City/State_______________________________ Zip code_____________
Jacket Size:__________________Height:_______________Weight_________________
What group best describes your race/ethnicity?
American Indian___
Caucasian___
African American___
Multiracial___
Asian___
Hispanic/Latino___
Southeast Asian Immigrant (Cambodian, Vietnamese, Laotian)___
Other_______________________________________ (Identify)
Citizenship
Are you a U.S. citizen? Yes___ No___
If no, what is your country of citizenship? _____________________________________
Are you a U.S. permanent resident? Yes___ No___
If yes, please provide your card number: ______________________________________
Date of issue:________________________________
2015 UMKC Summer Scholars Program
Application
Page 2
NOTE: Availability (Please check mark the appropriate response(s).)
I am available to attend all Summer Scholars classes during the period of July 13th to July
31.
___Yes
___No (if No, see below)
___My vacation plans conflict with the program dates July 13 – July 31, 2015.
___ I have enrolled in a program that may be a schedule conflict.
___Other_________________________________________________________
_________________________________________________________________
Science Preparation
Please check the courses you have taken previously.
Basic Chemistry ____
Advanced Chemistry (AP or IB) _____
Anatomy/Physiology_____
ACT Preparation__________
Have you taken the ACT or SAT? Yes________
No______
Do you consider yourself an advanced science student? If so, are you willing to
participate in daily chemistry enrichment and review?
Yes________
No___________________
What courses have been difficult for you, if any?____________________________
Interest in medicine and health careers: Please indicate how interested you are in
pursuing a career in medicine:
___Extremely interested
___Somewhat interested
___Interested
___Undecided
Do you have an interest in other health careers? If so, please indicate your interests
below:
____Nursing
____Dentistry
______Pharmacy
______Psychology/counseling
2015 UMKC Summer Scholars Program
Application
Page 3
1. Write a statement expressing your reasons for wanting to be in the Summer
Scholars Program. Include your general goals and career ambitions.
“I want to participate in the Summer Scholars Program because…”
2015 UMKC Summer Scholars Program
Application
Page Four
2. Significant School Activities (student government, athletics, clubs, tutoring,
etc.)
9th grade:
10th grade:
11th grade:
3. Offices held
9th grade:
10th grade:
11th grade:
4. Community Contributions (health-related experiences, volunteer work,
scouts, youth groups, etc.)
9th grade:
10th grade:
11th grade:
5. Summer Activities (travel, institutes, camp, etc.)
6. Employment (full and part-time -- with dates)
7. Current Hobbies and Leisure Time Interests
2015 UMKC Summer Scholars Program
Application
Page Five
Parental Permission
I have reviewed my child’s application for the UMKC Summer Scholars Program,
and as his/her parent or guardian, I give my permission for him/her to participate in
the program’s activities on the Hospital Hill campus.
Summer Scholars Outcomes Project: I also give permission for my child or
members of the family to be contacted in the future for the purpose of tracking future
career choices and outcomes.
___________________________________
Parent/Guardian Signature
_______________
Date
Transcript Release Permission
I hereby give my permission for a copy of a transcript of my grades and standardized
test scores to be sent to the UMKC Summer Scholars Selection Committee.
__________________________________
Parent/Guardian Signature
________________
Date
Note: Return this application to your guidance counselor as soon as possible.
THE APPLICATION DEADLINE TO GET THE APPLICATION TO YOUR
COUNSELOR IS APRIL 27, 2015.
2015 UMKC Summer Scholars Program
Application
Page Six
CONFIDENTIAL
TO BE COMPLETED BY MATH OR SCIENCE INSTRUCTOR
The following is my assessment of ________________________________________
concerning his/her aptitude for careers in the health sciences:
Name:_____________________________________ Title:_____________________
NOTE: THE APPLICATION DEADLINE TO GET THIS TO THE COUNSELOR IS
Promptly return this form to the Guidance Counselor who will send the completed
application materials to:
Kenneth Beene
Summer Scholars Program
UMKC School of Medicine
2411 Holmes
Kansas City, Missouri 64108-2792
2015 UMKC Summer Scholars Program
Application
Page Seven
CONFIDENTIAL
TO BE COMPLETED BY GUIDANCE COUNSELOR
The following is my assessment of ________________________________________
Concerning his/her aptitude for careers in the health sciences:
Name:________________________________________ Title: _________________
NOTE: THE APPLICATION DEADLINE IS Return this form with the student’s
completed application, transcript, list of current semester’s classes, and math or
science instructor’s confidential statement to:
Kenneth Beene
Summer Scholars Program
UMKC School of Medicine
2411 Holmes
Kansas City, Missouri 64108-2792