STUDENT DEMOGRAPHIC DATA Please print in ink clearly. Provide all information requested.

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1 AMSNY-Science & Technology Entry Program EINSTEIN ENRICHMENT PROGRAM Albert Einstein College of Medicine of Yeshiva University Application for Fall 2013 Admission DUE: June 13, 2013 STUDENT DEMOGRAPHIC DATA Please print in ink clearly. Provide all information requested. Name: Last First Middle Home Address: No. Street apt. City State zip Telephone # Cell # Facebook name: Twitter ID: Have you resided in New York State for the past 12 months? Yes No Date of Birth Sex: MALE FEMALE Place of Birth: Town/City Province / State Country Citizenship: USA Other Specify: Naturalization date (if applicable): Visa Type: Permanent Resident (Submit a copy of Permanent Resident card with this application) Other Ethnicity: Check One 1 Black/African American (includes all individuals from Africa or the Caribbean) Hispanic / Latino (please specify: ) American Indian/Alaskan Native Other 2 please specify 1 For the purpose of STEP, minorities historically underrepresented in the scientific, technical, health related and licensed professions include residents of New York who are Black or African American, American Indian, Alaskan Native, or Hispanic/Latino. 2 If you checked other, please refer to the Guidelines for Student Eligibility included in this packet to determine if you are economically disadvantaged. If you do not provide financial documentation as required by New York State, your application will not be accepted for review. 1

2 Submit your application by: June 13, 2013, 4:00 p.m. To: Coordinator, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Room B-407,, (718) Here is a checklist of the items needed to process your application. Make sure you have submitted fully completed forms to be considered for the STEP Program. Enclosed: Student Biographical data form (page 1) Academic data form (page 3) Other Activities & Family data form (page 5) Parental consent form (page 7) Recommendation form from school faculty member or advisor (page 11) Personal Essay describing your interests and goals in a health career see instruction below School Transcript- most recent Financial documentation Submit a SIGNED copy of 1040 Form for fiscal year 2012 ONLY if you did not check off Black/African American, Hispanic / Latino or American Indian/Alaskan Native on page 1. If you had your taxes submitted electronically, please print out a copy and sign the copy before you submit it to us. Instruction for PERSONAL ESSAY: Please include an essay of no less than one page and no more than two pages in response to the following questions: What are your general interests? What are your future educational aspirations? What are your future career aspirations? How do you think you would benefit from this program? The essay should be done on computer (or typed), double-spaced on white paper. 2

3 ACADEMIC DATA Name of High School: School Address: Bronx, NY Principal: Guidance Counselor: School phone: ( ) (ext) What grade are you starting in September 2013? Expected Graduation date: Current Average Current Class Ranking of STANDARDIZED TEST SCORES (Please answer all that apply) Write N/Y/T for any tests NOT YET TAKEN PSAT Verbal PSAT Math Date taken SAT I VERBAL SAT I MATH Date/s taken REG. MATH REG. SCI Date/s taken *Which math? * which SCI? REG. MATH REG. SCI Date/s taken *Which math? * which SCI? REG. MATH REG. SCI Date/s taken *Which math? * which SCI? GRADES FOR LAST MARKING PERIOD of Math GPA Science GPA Current Overall GPA 2. Will you be in a Regents curriculum in ? { }Yes { }No WHAT MATH AND SCIENCE COURSES ARE YOU TAKING IN THE FALL of 2013? (Please provide course number/name and indicate if it is a Non Regent (NR); Regent (R); or Advance Placement (AP) course. Algebra Geometry Pre-calc Calculus Trigonometry Other Math (name) Biology Chemistry Physics Other Science (name) 3 Submit a copy of your MOST RECENT transcript or grade report 3

4 Make sure you have answered all the questions about your academics and that you include a copy of your current school transcript. Now that you have told us about your grades, we would like to find out a little more about you. We also need to find out some information about your parents. Note: You only need to include family income if you are not a member of the underrepresented groups in medicine: African-or Caribbean-American, Native American or Alaskan Native, Latino/Hispanic. Remember. For the purpose of STEP, minorities historically underrepresented in the scientific, technical, health related and licensed professions include residents of New York who are Black or African American, American Indian, Alaskan Native, or Hispanic/Latino. If you checked other, please refer to the Guidelines for Student Eligibility on pages 6-7 to determine if you are economically disadvantaged. If you do not provide financial documentation as required by New York State, your application will not be accepted for review. 4

5 Other Activities Awards received during high school Extracurricular Activities: (sports, church, after school programs, part time work, etc.): Have you been able to define your career interests and set career goals? If yes, please describe Parent Information Student Resides With [ ] Mother and Father [ ] Mother [ ] Father [ ] Other: Identify Mother/Guardian First & Last Name Home Address House No./Street/Apt. No., City, State, Zip Home Phone No. cell No. Address Work Phone No. Father/Guardian First & Last Name. Home Address House No./Street/Apt. No., City, State, Zip Home Phone No. cell No. Address Work Phone No. If you checked Other for ethnicity on page 1, you must provide household income. If you did not check Other under ethnicity, disregard this box. HOUSEHOLD INCOME (Annual): $ Total No. in Household Source of Income: [ ] Employment [ ] Unemployment [ ] Social Services [ ] Social Security [ ] Other Parent s Signature Date 5

6 For those who need to qualify financially for the program, please review the eligibility information and submit your signed 2012 Income Tax Form or other documents listed in the guidelines 6

7 STEP Guidelines 2013 STEP Application STUDENT ELIGIBILITY The Science and Technology Entry Program is designed for New York State residents in grades 4 7 through 12 who are minorities historically underrepresented or economically disadvantaged in the scientific, technical, health-related, and licensed professions. Definitions: 1. For the purpose of STEP, a student is considered a New York State resident if he or she resides in New York State and has lived in New York State for the last two terms of school prior to entry into the STEP program or resided in New York State for at least 12 months immediately preceding the first term for which he or she is seeking participation in the STEP program. 2. For the purpose of STEP, minorities historically underrepresented in the scientific, technical, health-related, and licensed professions are Black or African-American, Hispanic/Latino, American Indian or Alaska Native. 3. For the purpose of STEP, a student is economically disadvantaged if he or she meets the eligibility requirements. ECONOMICALLY DISADVANTAGED ELIGIBILITY REQUIREMENTS 1. Economic Eligibility Criteria for First-Time Students -- A student is considered economically disadvantaged if he or she is a member of a household supported by one parent if dependent, by the student or by a spouse if independent, whose total annual income is not more than the applicable amount see chart below: Income Eligibility Criteria 2. Exceptions -- Reference to the household income scale need not be made if the student falls into one of the following categories, and documentation is available: a. The student's family is the recipient of: (1) Family Assistance Program Aid; or (2) Safety Net Assistance through the New York State Office of Temporary and Disability Assistance, or a county department of social services; or (3) family day-care payments through the New York State Office of Children and Family Services Assistance, or a county department of social services; b. The student is a ward of the State or a county. 4 For the purpose of the EEP is designed for 10 th through 12 th grade minorities historically underrepresented or economically disadvantaged. 7

8 3. Documentation -- The following shall be acceptable documentation of economic eligibility: 1. Documentation of all income, earned dividends and interest: a signed copy of your 2012 tax return (IRS forms 1040, 1040A, or 1040EZ; or 4506). 2. Documentation of a sole worker s income from two or more employers: W2s for the appropriate year or similar documentation acceptable to the Commissioner. 3. Documentation of no income: a copy of IRS form 4506 which has been filed by the student or family with the Internal Revenue Service or a copy of IRS Letter 1722 indicating that the student or parent did not file a return. 4. Documentation of pension, annuity, or unemployment benefits: letter from the applicable agency showing appropriate year's total award (if not reported on IRS forms 1040, 1040A or 1040EZ or 1099). 5. Documentation of social services payments: verification from a branch of the State Office of Temporary and Disability Assistance, Office of Children and Family Services Assistance, or a county department of social services showing year that benefits were received and names of recipients including the applicant. 6. Documentation of child support and/or alimony: a court order, affidavit. 7. Documentation of additional members in household: birth certificates, marriage certificates, thirdparty verification, or similar documentation acceptable to the Commissioner, along with proof of income or lack of income for each such member. 8. Documentation of zero household contribution: the needs analysis output form from one of the United States Department of Education s approved needs analysis systems. New York State Opportunity Programs Income Eligibility Criteria Number in Household Dependent on Income (& until further notice) This add-on allowance cannot be combined with the add-on amount shown below This add-on allowance cannot be combined with the add-on amount shown above $20,665 $27,991 $35,317 $42,643 $49,969 $57,295 $64,621 Add $5,570 for two workers or for one worker as sole support of a one-parent family* n/a Add $2,790 for a household supported by one member working two or more jobs at the same time n/a 8

9 PARENTAL CONSENT FORM I (print parent/guardian's name) and (print student's name) Grant permission to the an AMSNY-STEP Program housed at the Albert Einstein College of Medicine to: Collect school reports (transcripts, standardized scores, grade reports, etc.) Share student's name and contact information with other STEP / C-STEP programs, programs within Einstein, and college admissions offices from which your child might benefit. Student s Signature Date Parent s Signature Date BOTH SIGNATURES ARE REQUIRED 9

10 Give the following form to one of your high school teachers or counselors. You should submit the completed signed form in a sealed signed envelope with your application. 10

11 COUNSELOR LETTER OF RECOMMENDATION 2013 Admissions to A Science Technology Entry Program at the Albert Einstein College of Medicine Student: The is a pipeline program for minority and economically disadvantaged high school students who are seriously interested in pursuing a career in medicine or related health professions. The long range objective of the program is to increase the number of minority physicians and health care professionals. You have been selected by the applicant to submit a recommendation. Please fill out this form and provide us with some insight into the potential of this student. Most helpful are specific examples evidencing the student s personal and academic achievements. Check here if you would like your comments kept confidential: Please return this form to the student in a sealed/signed envelope for submission with the full application packet. poor Fair good excellent one of the best ever Academic performance Academic potential Character and maturity Enthusiasm and initiative Work ethic Why do you believe that this student is a good candidate for EEP? What can this student contribute to the program? How do you think this student will benefit from the program? Summary Evaluation I do not recommend this applicant for admission to your program. I believe that the applicant is marginally qualified for your program, but has potential. I recommend this applicant for admission to your program. I strongly recommend this applicant for admission to your program. Signature: Date: Name: School: Title and department: Telephone: ( ) Please use other side for additional comments if needed. You may supplement this recommendation form with a letter of recommendation, but the letter will not be accepted in lieu of the form. 11

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