Shsrp Application 10
- 1. Summer High School Research Program 2010 Student Application *Applications must be Postmarked by March 22, 2010* 1. _____________________________________________________________________________ First Name Middle Last 2. Mailing Address: ________________________________________________________________ Street ________________________________________________________________________________ City State Zip Code 3. _____________________________ ________________________ (Area Code) Telephone Number email address 4. Gender: Male Female 5. Are you citizen of the United States or a permanent resident: Yes No 6. High School (Name): __________________________________________________________________ High School Telephone Number (Include Area Code): ________________________ 7. Present Education Level: Junior Other: _____________________________________________________________________ 8. What are your goals in higher education? Degree(s)? _____________________________________________________________________ Major(s)? ______________________________________________________________________ 9a. On a separate sheet, attach an essay of not more than 300 words explaining why you wish to participate in this particular program and what you hope to achieve in the future. b. In addition to your essay, describe briefly your participation in SCIENCE activities, extracurricular activities, periodicals you subscribe to or read regularly and the titles of the last two books you read not required for class. -over-
- 2. 10. Ethnicity (Optional): Native American Hispanic/ Mexican American Pacific Islander Caucasian Asian/Indian Alaskan Native African American Other: __________________________ 11. ______________________ _______________________________________________ Date Signature of Applicant 12. CONSENT: It is my understanding that, if enrolled, students will be subject to the regulations of their assigned research institutions and the program. I am aware that my child has applied for the American Cancer Society, Illinois Division’s Summer Research Program. ______ __________________ _____________________________________________ Date Signature of Parent/Guardian PLEASE RETURN YOUR APPLICATION TO YOUR ADVISOR FOR MAILING. 13. ACADEMIC ADVISOR: In the space provided please record the GPA average of all science and mathematics courses (for grades 9 and 10) for this student. Include student’s current math/science class averages as of the end of the first semester, junior year. Attach a transcript of grades as of the end of first semester, junior year. Science Mathematics/ Computer Science 9th & 10th Grade Science ______ Algebra I ______ Earth Science ______ Geometry ______ Biology ______ Algebra II/Trigonometry ______ AP Biology ______ Pre Calculus ______ Chemistry ______ AP Statistics ______ Other: ______ Other: ______ ________________ ______ ___________________ ______ ________________ ______ ___________________ ______ 14. PLEASE CALCULATE the unweighted GPA average of all science/math courses final and current grades: __ __ . __ __ 15. Estimated student rank in the junior class: __________ out of ____________________ students. (If Available) Student PSAT score: Overall selection index percentile: ___________ %. Student SAT scores: Verbal: _______ _______ %; Quantitative: _______ _______ %. (If Available) Or Student ACT scores: ______________________________________ _____________ 16. ACADEMIC ADVISOR: Please include other qualifications and/or characteristics about the candidate, which might be pertinent to the application. ______________________ ______________________________________________________ Date Signature of Academic Advisor **Please verify that all sections of the student’s application is complete, i.e., essay, transcripts and letters of recommendation. Please Return All Applications with Essay, Letters of Recommendation and Transcripts to: American Cancer Society, Illinois Division c/o Summer High School Research Program 225 N. Michigan Avenue, Suite 1200 Chicago, IL 60601 Conflict of Interest: The selection of students is managed by an independent review panel. Immediate family members of individuals on the independent review panel are not eligible for the Summer High School Research Program. Immediate family members of staff are not eligible for the Summer High School Research Program. All other applications will be subject to the Conflict of Interest Policy.