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Embed code for: Final_SURE_program_Application_2017
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Name: (First) (Middle): Last: Date of birth: Age On June 15, 2016: Check One: Male Female Home Phone: ( ) Cell Phone: ( ) Mailing Address: City: State: Zip Code: Physical Address (If different from mailing address): City: State: Zip Code: Student Email: U.S. Resident: Yes: No: SCINTILLON INSTITUTE SURE PROGRAM APPLICATION Section A: Personal Information Section B: Personal Information Section C: Academic Information Current School Attending: School District: Magnet Program (If available): Grade Level In Fall 2016: School and Community Activities/Clubs/Leadership Positions: Pg. 1 of 2 ProfessionalMaster’s Degree Bachelor’s DegreeAssociate’s Degree Some CollegeHigh School Diploma/G.E.D Guardian’s Name(2): Email: Address: Phone: City: State: Zip Code: Level of Education: ProfessionalMaster’s Degree Bachelor’s DegreeAssociate’s Degree Some CollegeHigh School Diploma/G.E.D Guardian’s Name(1): Email: Address: Phone: City: State: Zip Code: Level of Education: SCINTILLON INSTITUTE SURE PROGRAM APPLICATION Section D: Essay, Transcripts & Letters of Recommendation Section E: Signatures Student Essay: Your essay should NOT exceed one, double spaced page. Describe yourself and discuss EACH of the following as part of your essay. You are NOT limited to these areas. 1. Important academic experiences 2. Extracurricular activities that have influenced you in a positive way 3.A hardship that you have overcome 4.Your passion for science and for learning 5. Expectations from this program and your plans for the future Grade Transcripts: Include an official copy of your current high school transcript. Letters of Recommendation: Include two letters of recommendation: at least one should be from a science teacher. The letters should include, but are not limited to the description of the student’s capabilities, a discussion of charac- ter traits and provide specific reasons why they are well suited for participation in this program. Please provide each teacher a copy of the teacher recommendation form to accompany their letter of recommendation. Consent to Release Information Record Pursuant to the Family Education Rights and the Privacy Act of 1974, which requires written consent for the release of information outside of school, Scintillon Institute respectfully seeks the right to request the release of any or all educational records as listed below if needed: • Record of grades (Transcript) • Class rank • GPA (Grade point average) • Standardized test scores • Email address (to be used for communication between students and Scintillon Institute, other programs students, and/or potential mentors) • Students photo (photos are taken during Scintillon Institute activities- they are used for publications, website, videos representing the Scintillon Institute) • Information gathered in focus groups for evaluation purposes Parents: By signing below, you are giving your consent for your son or daughter to apply and participate in Scintillon Institute's SURE program with the expectation that this could be a 3-year commitment. You are also giving your consent for the Scintillon Institute to access the above mentioned information and records for the purposes of applicant selection, program marketing, and publication. Student’s Signature: Date: Guardian’s Signature: Date: Pg. 2 of 2