Gladstone/National Student Leadership Conference Scholarship

Gladstone/National Student Leadership Conference Scholarship

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Gladstone/National Student Leadership Conference Scholarship
Medicine & Health Care program Informational Flyer
About Gladstone Institutes
For more than 30 years, the Gladstone Institutes (Gladstone) has focused its biomedical research on three significant disease areas:
heart disease, HIV/AIDS, and neurological diseases. In 2005, our outreach efforts were formalized through the creation of a Student
Outreach Committee and a community outreach program dedicated to promoting science education and scientific careers for
disadvantaged students in San Francisco public schools.
About our partnership with National Student Leadership Conference (NSLC)
Each summer, Gladstone grants 28 full-ride tuition scholarships (valued at approximately $2,500 each) to SFUSD Sophomores and
Juniors to attend NSLC’s 10-day summer program at UC Berkeley that exposes students to medicine & health care careers. NSLC
has been around for over twenty years and thousands of outstanding high school students from across the United States and more than
70 countries have come to the NSLC to gain an insider’s perspective on today’s most exciting professions and to further their
leadership development. At the NSLC, students have the opportunity to explore a career and experience college life and degree
programs, while making new friends, meeting with leading professionals and experts, visiting prominent organizations, and touring
exciting cities. Please DO NOT register with the NSLC directly and/or pay their deposit, for it is non-refundable. If you receive the
scholarship given by Gladstone you will be able to attend NSLC for free!
About the Medicine and Healthcare Program
Each NSLC program is designed to introduce students to the vast number of careers and opportunities available within their area of
interest. The program’s academic lectures and hands-on simulations are taught at a college freshman level. With the help of guest
lecturers and professors, the students will discuss:
• Medicine in the 21st Century
• Medical Ethics
• Global & Public Health
• A Day in the Life of a Surgeon
• Toxicology
• Biomedical Engineering
Throughout the conference, the students will hear from a variety of guest speakers and participate in
workshops designed to develop leadership skills essential for success in various medical fields.
Students will also take part in hands-on simulations during which they will suture, perform dissections,
diagnose standardized patients, and learn a variety of clinical medicine skills.
During each 10-day session, students will visit local medical facilities and institutions and tour some of
San Francisco’s most famous attractions. Past trips and tours include:
• Gladstone Institutes
• University of California, Berkeley School of Optometry
• American Red Cross – Oakland Donor Center
• California Academy of Sciences
• Exploratorium
• Pier 39
The Students
NSLC students are curious, intelligent, motivated, and have a wide range of interests and life
experiences. Approximately 150 students will travel from across the United States and the world to
attend each conference.
2013 Dates
NSLC students will reside at the University of California, Berkeley during the entire 10-day
conference. The summer 2013 dates are as follows:
• June 24 – July 3, 2013
• July 7 – July 16, 2013
• July 20 – July 29, 2013
• August 2 – August 11, 2013
UCSF Mission Bay Campus
1650 Owens Street, San Francisco, CA 94158
www.gladstone.ucsf.edu
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National Student Leadership Conference (NSLC) Scholarship
Gladstone Application Form
Deadline: Friday, March 1, 2013
Applicant Information
Student’s Full Name: ________________________________________________________________________
Last
First
High School: _______________________________
Middle Initial
Grade Level (currently for 10th & 11th graders): q 10th q 11th
Ethnicity: Information on ethnicity is used for demographic purposes only. Gladstone is firmly committed to
encouraging diversity in its programs.
□ (1) African American / Black
□ (9) Pacific Islander
□ (2) American Indian / Alaskan Native □ (10) Vietnamese / Vietnamese American
□ (3) Chinese / Chinese American
□ (11) White / Caucasian
□ (4) East Indian / Pakistani
□ (12) Other Asian
□ (5) Filipino / Filipino American
□ (13) Other Spanish American / Latino
□ (6) Japanese / Japanese American
□ (14) Other
□ (7) Korean / Korean American
□ (15) Decline to State
□ (8) Mexican / Mexican American / Chicano
Primary Language(s) Spoken at Home: ____________________________________________________________
Total Family Income:
(1) q Less than $20,000
(4) q $30,000 - $34,999
(7) q $45,000 - $49,999
(2) q $20,000 - $24,999
(5) q $35,000 - $39,999
(8) q $50,000 - $54,999
(3) q $25,000 - $29,999
(6) q $40,000 - $44,999
(9) q $55,000 or greater
Number of people living in your household (including yourself): _______________________________________
Parents/Guardian Education:
What is your parent or guardian’s highest level of education? (please check one)
□ Did not graduate from high school
□ Some college but no Bachelor’s degree
□ High school graduate
□ 4-year college graduate or higher
Relationship to you: ______________________________________________________________________
If applicable, what is your other parent or guardian’s highest level of education? (please check one)
□ Did not graduate from high school
□ Some college but no Bachelor’s degree
□ High school graduate
□ 4-year college graduate or higher
Relationship to you: ______________________________________________________________________
College Preparation:
Have you participated in any college preparation or academic enrichment programs? qYes qNo
If yes, please describe/list program name: _________________________________________________________
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National Student Leadership Conference (NSLC) Scholarship
Gladstone Application Form
Deadline: Friday, March 1, 2013
Personal Statement
On a separate piece of paper, handwrite legibly or type one paragraph (200 words max) on each of the following
questions for four paragraphs total. Each question should be answered in full sentences, not bulleted lists.
1. Tell us about any extracurricular activities, volunteer, or work experience that you have been involved with
in high school. (Ex. after-school programs, church, school clubs, community service, employment, etc.). Be
sure to highlight any leadership roles you have held.
2. Discuss how attending the National Student Leadership Conference will enhance your academic potential
and increase your participation as a leader in your school/community.
3. Briefly describe your family’s economic background. Include information about your financial challenges.
4. Please describe your future plans in medicine, scientific research and/or health care.
Letter of Recommendation
Please submit one letter of recommendation from a SFUSD teacher (math, science, or health) or your counselor. Use
the attached form or have them write a letter on school letterhead indicating how long they have known you, what
class(es) you have taken with them, and why they think you are a good candidate for this program.
Student Commitment
I understand that the Gladstone/NSLC program exposes students to medical and health care fields, and if accepted, I
intend to participate fully. I also understand that I must commit to the entire 10-day residential program at UC
Berkeley, which means living on campus for the entire 10-day period and attending a pre-summer orientation and
post-summer closing celebration at the Gladstone Institutes in San Francisco.
Student Signature: ____________________________________________
Date: _____________
Parent/Guardian Permission
I give permission for my child to attend the Gladstone/NSLC program. I understand that, if accepted, my child must
commit to the entire 10-day residential program at UC Berkeley, which includes living on-campus in dorms with a
roommate of the same gender for the entire 10-day period. All meals are provided, but $60 of spending money is
suggested for three meals off campus and laundry. I will also support my child’s attendance at the pre-summer
orientation and post-summer closing celebration at the Gladstone Institutes in San Francisco.
Parent’s/Guardian Signature: ____________________________________
Date: _____________
Please send your completed application to us by the postmarked deadline of Friday 3/1:
Paul Li
The Gladstone Institutes
1650 Owens Street
San Francisco, CA 94158
or FAX it to us at: #415-355-0826
Completed application checklist:
____ Gladstone Application Form
____ NSLC Scholarship Form
____ Personal Statement
____ Letter of Recommendation
If you or you have any questions please email or call us at:
Email: [email protected]
Phone: #415-734-2593
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National Student Leadership Conference
Medicine & Health Care program
10-day summer session at UC Berkeley
NSLC Scholarship Form
Deadline: Friday, March 1, 2013
1. PROGRAM SELECTION: Please list your 1st, 2nd, 3rd, and 4th session choices in numerical order. If your first choice is not available, you will be registered for your next available alternative. If there is a session that you cannot attend, please leave that choice blank. If you receive the scholarship, you must available to live on campus at UC Berkeley for the entire 10-­‐day session for which you are chosen. Please DO NOT register with the NSLC directly and/or pay their deposit, for it is non-­‐refundable. If you receive the scholarship given by Gladstone you will be able to attend NSLC for free! NSLC Medicine & Health Care University of California, Berkeley (San Francisco) ____ June 24 – July 3, 2013 ____ July 7 – July 16, 2013 ____ July 20 – July 29, 2013 ____ August 2 – August 11, 2013 2. STUDENT INFORMATION: Please write legibly! ALL INFORMATION IS ONLY FOR NSLC USE, ALL FIELDS ARE REQUIRED. Name: Last: ____________________________ First: ________________________________________ Middle Initial: ____ Gender: □ Male □ Female Nick Name/Name for nametag (if different than First Name above): __________________________________________________________________________ Social Security Number:__________________ OR Non US Citizen Passport #: _______________ Passport Country_____________ OR Tax ID: ________________ Permanent Address: Street/P.O. Box ______________________________________________________________City:___________________________________ State: ______________ Zip Code: _______________________ __Country: _____________________________________ Date of Birth: ______/________/______ Home Phone: (_____) _____________________ Student Cell: (______) ____________________ Student E-­‐mail: _______________________________________ High School Graduation Year: _______________ Current Grade Point Average (GPA): ______on a scale of: ______ High School: ___________________________ School Phone: (______) ________________ Counselor Name: _____________________________ Counselor Email: ____________________________________ High School Address: Street/P.O. Box: ______________________________________________________________________________________________ City: _______________________________________________ State: ________________________ Zip Code: __________________ 3. PARENT/GUARDIAN INFORMATION: Please write legibly, we must be able to email and/or call both students and parents! Parent/Guardian Name: __________________________________________ Relationship to Student: ________________________________________________ Address (if different from student’s):__________________________________________________Parent Email: ________________________________________ City:_________________________________ State:_________________ Country:________________________________ Zip Code:________________________ Phone: Home: (________)__________________________ Work: (_________)______________________________Cell: (_________)_______________________ 4. SCHOLARSHIP INFORMATION: The J. David Gladstone Institutes includes the tuition for the National Student Leadership Conference on Medicine & Health Care. The tuition covers housing accommodations, all meals but 3, transportation during the program, course materials, and admission to various events throughout the program’s schedule. 5. STUDENT AND PARENT/GUARDIAN AGREEMENT: A comprehensive Code of Conduct, which details guidelines for behavior and prohibits possession of such substances as drugs, alcohol, and tobacco will be included in the student’s Acceptance Packet. I understand that this form and other required forms must be signed and returned in order to participate in the NSLC. I further understand that failure to abide by this code of conduct may result in my immediate dismissal, return home at own expense, and forfeiture of the awarded scholarship. ______________________________________________ Student Name (please print) _______________________________________________________ Student Signature ________________ Date _____________________________________ ____________________________________________ Parent/Guardian Name (please print) Parent/Guardian Signature _____________ Date Page 5 of 5
National Student Leadership Conference (NSLC) Scholarship
Teacher/Counselor Recommendation Form
Deadline: Friday, March 1, 2013
TO BE COMPLETED BY STUDENT:
Student Name: ______________________________
List ALL High School Math & Science Classes that you have taken
or are currently enrolled in:
SFUSD High School: _________________________
Math: __________________________________________________
School Counselor: ___________________________
Science:_________________________________________________
Overall GPA: _______________________________
TO BE COMPLETED BY A TEACHER (Science, Math, or Health) OR A COUNSELOR
(Please use additional paper if necessary):
1. How long and in what capacity have you known the applicant?
__________________________________________________________________________________________
__________________________________________________________________________________________
2. Do the student’s grades reflect his/her ability and effort?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
3. Why would you recommend the applicant to the Gladstone/NSLC program?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
I have reviewed the Gladstone/NSLC flyer and am familiar with the above student applying for admission. I believe the
above student would contribute to the diversity and academic quality of the student body of the NLSC. This student has
the maturity to live on a University campus and work with other students in an academic environment. I hereby
recommend this student for admission. Grade information below is for teachers only, counselors can leave it blank.
Recommender Print Name: _________________________
Email: _______________________________________
Recommender Signature: ___________________________
Title/Position:__________________________________
Student’s Fall letter grade in your class: _______________
Spring current grade in your class: _________________