2015 UMKC Summer Scholars Program Application

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1 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: 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

2 If yes, please provide your card number: Date of issue: 2015 UMKC Summer Scholars Program 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 13 th to July 31. Yes No (if No, see below) My vacation plans conflict with the program dates July 13 July 31, 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 Anatomy/Physiology Advanced Chemistry (AP or IB) 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 Interested Somewhat interested Undecided

3 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 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

4 Page Four 2. Significant School Activities (student government, athletics, clubs, tutoring, etc.) 9 th grade: 10 th grade: 11 th grade: 3. Offices held 9 th grade: 10 th grade: 11 th grade: 4. Community Contributions (health-related experiences, volunteer work, scouts, youth groups, etc.) 9 th grade: 10 th grade: 11 th grade: 5. Summer Activities (travel, institutes, camp, etc.) 6. Employment (full and part-time -- with dates) 7. Current Hobbies and Leisure Time Interests

5 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.

6 Page Six C O N F I D E N T I A L 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

7 Page Seven C O N F I D E N T I A L 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

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