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Office of Educational Outreach

Saturday Biomedical Science Academy

Please complete the following application.
Fields in bold are required. Applications for this program will be accepted through 12:00:00 AM Friday, October 11, 2013.

Contact Information
Education
Participation
Supplemental

Student Information
1.	First Name
2.	Middle Initial
3.	Last Name
4.	Address
5.	City
6.	State
7.	Zip Code
8.	Primary Phone
9.	Date of Birth
Contact Information
1.	Parent/Guardian Name
2.	Parent/Guardian Home Phone
3.	Parent/Guardian Work/Cell Phone Number
4.	Parent/Guardian Email Address
5.	Emergency Contact Name
6.	Emergency Contact Phone
7.	Emergency Contact Relationship

Education
1.	What is the name of the school you currently attend?
2.	School district
					4th	5th	6th
3.	What is your current school grade?
				Regular	Accelerated	Honors	Gifted
4.	What is your current school program type?
					Yes	No	Unsure
5.	Do you plan to attend college?
5.	If yes, what is your major (if known):
6.	List academic honors/awards which you have received or for which you have been nominated. 1000 characters remaining
7.	What are your favorite subjects? 1000 characters remaining
8.	What career(s) are you interested in pursuing? 1000 characters remaining
9.	List any school, church or community activities in which you have participated. List your hobbies, interests and/or special skills. 1000 characters remaining

Participation
1.	Do you have any brothers, sisters and/or other relatives who have participated in any UTMB science enrichment programs? If so, which programs? 1000 characters remaining
2.	Participants in this program are required to be present each Saturday of the three sessions (Nov. 9, Nov. 23 and Dec. 7). Do you have any conflicting commitments? State reason, time(s) and/or date(s). All participants must attend the opening session on Nov. 9 and the closing session on Dec. 7. No exceptions! 1000 characters remaining

3.	On a scale of 1-10 (10 = highest), rank your desire for participation in this program.
3.
4.	On a scale of 1-10 (10 = highest), rank your parents' desire for your participation in this program.
4.
5.	Please write an essay (100 words or less) that includes answers to the following questions: 1) Why would you like to participate in this program? 2) Why is science important to you? 1000 characters remaining

Supplemental Information This information is requested for statistical data only. It is NOT part of the application and will NOT impact your admission into the program.
						Female	Male
1.	Gender
		Grades 9-12	H.S. diploma	1-2 years of college	3+ years of college	College graduate	Other / Advanced Degree
2.	Mother's Educational Background
2.	If other/advanced degree, please specify:
3.	Father's Educational Background
3.	If other/advanced degree, please specify:

4.	Disadvantaged Status (check if applicable)
4.	Economic (based on federal guidelines) Physical (a disabled person is an individual with a physical impairment which substantially limits one or more of such person�s major life activities) Geographic - Urban Geographic - Rural Educational (persons in this category have limited educational opportunities available to them, usually because of school size and funding)

5.	Race / Ethnic Classification
5.	Asian or Pacific Islander Black (Non-Hispanic) Hispanic Native American White (Non-Hispanic) Other If other, please specify:

Please review your application and then click "Submit" to proceed.

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301 University Boulevard, Galveston, Texas, 77555-0919 UTMB Maps