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Office of Educational Outreach

Summer Biomedical Health Careers Academy

Please complete the following application. This academy is for high school students, age 16 or above by program start date.
Fields in bold are required. Applications for this program will be accepted through 12:00:00 AM Friday, April 26, 2013.

Student Information
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.	Email Address
10.	What is the name of the high school that you currently attend?
11.	What is the name of your school district?
				9th	10th	11th	12th
12.	What is your current school grade?
13.	Date of Birth
						Yes	No
14.	Are you a US citizen or permanent resident?
15.	List all countries in which you resided:
16.	List all countries in which you are a citizen:

Contact Information
1.	Parent/Guardian Name
2.	Parent/Guardian Email Address
3.	Parent/Guardian Work/Cell Phone Number
4.	Emergency Contact Name
5.	Emergency Contact Phone
6.	Emergency Contact Relationship

Education
				Math	Writing	Reading	Comp
1.	PSAT/SAT Score
		English	Math	Reading	Reasoning	Writing	Comp
2.	ACT Score
3.	Please answer the following as they pertain to science and mathematics: 1) awards received; 2) participation in special programs; 3) science fair projects and awards; 4) club memberships (include any officer positions); 5) other projects / competitions. 1500 characters remaining
4.	Please answer the following as they pertain to academic honors and extracurricular involvement: 1) academic awards; 2) community awards; 3) school activities and organizations; 4) civic, volunteer and church activities; 5) hobbies / interests. 1500 characters remaining

Participation
						Yes	No
1.	Have you participated in this academy or a similar science enrichment program before?
1.	If so, what program and when?
						Yes	No
2.	Participants in this program are required to be present for the entire duration of the program. Do you have any conflicting commitments for this program?
2.	If yes, state reason, times and/or dates:
						Yes	No
3.	Will you have to make arrangements to live within a commuter distance? If yes, you must submit a letter with your supporting documentation to confirm local residence.
4.	Please explain what attracts you to the UTMB Summer Biomedical Health Careers Academy and what you hope to gain from this experience. Explain what areas of science particularly interest you. You should state your favorite subject(s), if you plan to attend college, expected major and career ambitions. 1500 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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