TheCenterforYouthEducation’sScienceandTechnologyEntryProgramanditsactivitiesaresupported,inwholeorinpart,byagrantfromtheNewYorkStateEducationDepartment
Ph: 212-241-7655 Fax: 212-358-1059 Email: [email protected]
ScienceandTechnologyEntryProgramSUMMER2016APPLICATIONFORM
Date:________________ CurrentGradeLevel:_________OSISID#(9digitIDontranscript):_______________Program(s)ofinterest(pleaserank):1.2.3.DEMOGRAPHICDATA PrintName: First Middle Last HomeAddress: HouseNo./StreetName/Apt.No. City,State,ZipE-mailAddress:______________________HomePhoneNo:___________________________ CellPhoneNo:_______________________ FacebookName:___________________________ TwitterID:__________________________DateofBirth:______________________________ Gender:[]Male []FemaleNYStateResident:[]Yes[]No PlaceofBirth:_______________________ City/Town/CountryU.S.Citizen []Yes[]No PermanentResident:[]Date: VisaType: Ethnicity:(CheckOne)
ACADEMICDATA(Allapplicantsmustsubmittheirmostrecentreportcardortranscriptwiththisapplication)HighSchool:_______________________________________________________________________Address:__________________________________________________________________________GuidanceCounselor:____________________________Phone#:___________________________Doyoucurrentlyreceivefreeorreducedmealsatschool(documentationrequired)?☐YES☐NO
[]African-American/Black []Hispanic/Latino(specify)[]AmericanIndian/AlaskaNative []Other(pleasespecify)*
TheCenterforYouthEducation’sScienceandTechnologyEntryProgramanditsactivitiesaresupported,inwholeorinpart,byagrantfromtheNewYorkStateEducationDepartment
Ph: 212-241-7655 Fax: 212-358-1059 Email: [email protected]
STANDARDIZEDTESTSCORESPleaseanswerallthatapply–WriteN/Y/Tforanytests“NOTYETTAKEN”PSATVerbal__________ PSATMath__________________Datetaken___________SATIVERBAL________SATIMATH_________________Date/staken___________REG.MATH___________________Score_____________Date/staken_______________REG.SCI_______________________Score_____________Date/staken______________SATII:(SubjectName)___________________(Score)____________DateTaken____________SATII:(SubjectName)___________________(Score)____________DateTaken____________
GRADESFORLASTMARKINGPERIOD1.MathGPA__________ScienceGPA_________ CurrentOverallGPA_______(GradereportMUSTverify)2.WillyoubeinaRegentscurriculumin2015-2016?☐YES☐NO
MATHANDSCIENCECOURSESINSPRING2016Pleaseprovidecoursenumber/nameandindicateifitisaNonRegent(NR);Regent(R);orAdvancePlacement(AP)courseAlgebra____________________________ Biology___________________________________Geometry__________________________ Chemistry________________________________Pre-Calculus_______________________ Physics___________________________________ Calculus____________________________ OtherScience(name)___________________Trigonometry______________________OtherMath(name)_______________
PreviousMountSinaiProgram(s):_______________________________________________________________________________________________________________________________________________________________________________________________
TheCenterforYouthEducation’sScienceandTechnologyEntryProgramanditsactivitiesaresupported,inwholeorinpart,byagrantfromtheNewYorkStateEducationDepartment
Ph: 212-241-7655 Fax: 212-358-1059 Email: [email protected]
Pleaselistawardsreceivedinhighschool Pleaselistextracurricularactivities(school,community,church,involvementinotherprograms): Whatareyourcareerinterests?
FAMILYDATA StudentResidesWith[]MotherandFather[]Mother[]Father[]Other Mother/Guardian First&LastName HomePhoneNo.HomeAddress HouseNo./Street/Apt.No.,City,State,ZipEmailAddress WorkPhoneNo.
Father/Guardian First&LastName HomePhoneNo.HomeAddress HouseNo./Street/Apt.No.,City,State,Zip
EmailAddress WorkPhoneNo.
EmergencyContactName:___________________________________________________________________________________
EmergencyContactPhone#:_________________________________________________________________________________
TheCenterforYouthEducation’sScienceandTechnologyEntryProgramanditsactivitiesaresupported,inwholeorin
part,byagrantfromtheNewYorkStateEducationDepartment
Ph: 212-241-7655 Fax: 212-358-1059 Email: [email protected]
APPENDIXGUIDELINESFORSTUDENTELIGIBILITY
TheScienceandTechnologyEntryProgramisdesignedforstudentsattendingsecondaryschool(grades7-
12)inNewYorkStatewhoareeitherminoritieshistoricallyunderrepresentedinthescientific,technical,
healthrelatedandlicensedprofessions,oreconomicallydisadvantagedasdefinedbelow.ForthepurposeofSTEP,minoritieshistoricallyunderrepresentedinthescientific,technical,healthrelatedand
licensedprofessionsincluderesidentsofNewYorkStatewhoareAfricanAmerican,AmericanIndian/AlaskaNativeorHispanic.Ifyouareeconomicallydisadvantaged,youmaybeeligibleforSTEP.Please
refertotheguidelinesbelowandprovidetherequireddocumentation.
ForthepurposeofSTEP,astudentisconsideredaNewYorkStateresidentifheorsheresidesinNewYork
StateandhaslivedinNewYorkStateforthelasttwotermsofschoolpriortoentryintotheSTEPProgram,or
hasresidedinNewYorkStateforatleast12monthsimmediatelyprecedingthefirsttermforwhichheorshe
isseekingparticipationintheSTEPProgram.
The economic eligibility standards set forth in this Appendix apply only at the time of application to the
ScienceandTechnologyEntryProgram.Onceadmitted,aparticipantmaycontinuetoreceiveservices,even
ifthefamilyincomerisesabovethecurrenteligibilitystandards.
1. EconomicEligibilityCriteriaforFirst-TimeStudents
ForthepurposeofSTEP,astudentiseconomicallydisadvantagedifheorshemeetstheincomeeligibility
criteriaoutlinedinthetablebelow(economicdisadvantagedocumentationwouldbeacopyoftheparentor
legalguardian’ssignedmostrecentyear’staxreturns(IRSform1040,1040A,1040EZor4506).
Additionaldocumentationofhouseholdincomeneednotbecollectedtodetermineeligibilityundereconomicdisadvantageifthestudentfallsintooneofthefollowingcategories,anddocumentationisavailabletodemonstrate:
• Thestudent'sfamilyistherecipientoffamilyassistanceprogramaidorsafetynetassistance
throughtheNewYorkStateOfficeofTemporaryandDisabilityAssistanceoracountydepartment
ofsocialservices;oristherecipientoffamilyday-carepaymentsthroughtheNewYorkState
OfficeofChildrenandFamilyServicesoracountydepartmentofsocialservices;
• Thestudentislivingwithfosterparentsandnomoniesareprovidedfromthenaturalparents;or
• ThestudentisawardoftheStateoracounty.
• Thestudentreceivesfreeorreducedlunchathisorhersecondaryschool(verifiedbytheschool).
NumberinHouseholdDependingonIncome 2015-16
1
2
3
4
5
6
7
$21,755
$29,471
$37,167
$44,863
$52,559
$60,255
$67,951*
4Add$7,696foreachfamilymemberinexcessof7.
TheCenterforYouthEducation’sScienceandTechnologyEntryProgramanditsactivitiesaresupported,inwholeorinpart,byagrantfromtheNewYorkStateEducationDepartment
Ph: 212-241-7655 Fax: 212-358-1059 Email: [email protected]
2. Exceptions
Reference to the household income scale need not be made if the student falls into one of thefollowingcategoriesanddocumentationisavailable:
a. The student’s family is the recipient of (1) Family Assistance Program Aid, or (2) Safety NetAssistancethroughtheNewYorkStateOfficeofTemporaryandDisabilityAssistance,oracountyDepartment of Social Services, or (3) family day care payments through the New York StateOfficeofChildrenandFamilyServicesAssistance,oracountyDepartmentofSocialServices.
b. ThestudentisawardoftheStateoracounty.
3. Documentation
PleaseprovideonlyONEofthefollowingdocuments.
Thefollowingshallbeacceptabledocumentationofeconomiceligibility:
a. Preferred-Reducedorfreelunchdocumentationfromhighschoolorthestate.
b. Documentationofallincome,earneddividendsandinterest:asignedcopyofappropriateyear’staxreturn(IRSForms1040,1040A,1040EZ,or4506).
c. Documentation of a sole worker’s income from two or more employers: W2’s for theappropriateyearorsimilardocumentationacceptabletotheCommissioner.
d. Documentationofnoincome: acopyofIRSForm4506whichhasbeenfiledbythestudentorfamilywiththeInternalRevenueServiceoracopyofIRSLetter1722indicatingthatthestudentorparentdidnotfileareturn.
e. Documentation of pension, annuity, or unemployment benefits: letter from the applicableagency showing appropriate year’s total award (if not reported on IRS Forms 1040, 1040A,1040EZor1099).
f. Documentation of Social Security, Supplemental Security Income, or Veterans Administrationnon-educational benefits: a letter from the applicable agency showing applicable year’s totalawardforeachmemberofthehousehold, includingMedicarepremiumsorIRSForm1099foreachmemberofthehousehold.
g. Documentation of Social Services payments: verification from a branch of the State Office ofTemporary and Disability Assistance, Office of Children and Family Services Assistance, or acounty department of Social Services showing year that benefitswere received and names ofrecipientsincludingtheapplicant.
h. Documentationofchildsupportand/oralimony:acourtorder,affidavit.
i. Documentation of additional members in household: birth certificates, marriage certificates,third-party verification, or similar documentation acceptable to the Commissioner, alongwithproofofincomeorlackofincomeforeachsuchmember.
4. OSISIDNYCDOEOSISnumberisanine-digitnumberthatisissuedtoallstudentswhoattendaNewYorkCitypublicschool.ThenumbercanbefoundonyourIDcardortranscript.
TheCenterforYouthEducation’sScienceandTechnologyEntryProgramanditsactivitiesaresupported,inwholeorinpart,byagrantfromtheNewYorkStateEducationDepartment
Ph: 212-241-7655 Fax: 212-358-1059 Email: [email protected]
MedicalCertificationForm
Student’sName:______________________________________________________ Last4digitsofSocialSecurity_________ Last First(___)Ihaveexaminetheabovenameson,_____________andfoundhim/hertobemedicallyfitandcapableofperformingallassignedduties.(___)Theabovenamedhasaconditionthatwillaffecthis/herabilitytofunctioneffectivelyandmayputothersatrisk(pleasedescribethecondition):Immunizations:1. P.P.D. Negative___________ Positive___________
DateGiven___________ DateRead___________
[IftestisfoundtobepositivepleaseattachChestX-Ray.PPDmustbewithinthelast6months.StudentswithaPPDconversioninthelast12monthmustshowproofoftreatmentandprovideaChestX-Ray.]
2. M.M.R.orTiter* Dates_______________________*Immune___________NotImmune____________Datetested_____________
3.HepatitisB Dates_____________________________________4.TDaP Date____________5.Varicella Dates____________ ______________6.Asthma Yes__________ No________________________________________________________________________________________________________Physician’sName(Print) Address_____________________________________________________________________________________________Physician’sSignature City/State/Zip_____________________ _______________________________________________________________Date Telephone
TheCenterforYouthEducation’sScienceandTechnologyEntryProgramanditsactivitiesaresupported,inwholeorin
part,byagrantfromtheNewYorkStateEducationDepartment
Ph: 212-241-7655 Fax: 212-358-1059 Email: [email protected]
MedicalAttentionConsentForm
DearParent:
Weaskyourpermissiontoextendmedicalattentiontoyourson/daughter–asaparticipantintheMount
SinaiCEYEProgram–shouldanemergencyarise.
PleaseindicateyourconsentfortheHospitaltotreatyourchildincaseofanemergency,bycompleting
andsigningthebottomportionofthisletter–andreturningitimmediatelytotheprogramoffice.A
chargeforthisservicemayapply.
Sincerelyyours,
AlysonDavis,LMSW
ProgramManager
IgivepermissiontoTheMountSinaiHospitaltoextendmedicalattentionandtreatmenttomy
child,_______________________________________________shouldanemergencyariseduringthehoursthathe/she
isinattendanceattheMountSinaiCEYEProgram.
MedicaidNo./Type____________________ __________________________
OrOtherInsurance____________________ Parent/Guardian(Print)
ExpirationDate____________________
__________________________
Parent/Guardian(Signature)
__________________________
Date
TheCenterforYouthEducation’sScienceandTechnologyEntryProgramanditsactivitiesaresupported,inwholeorinpart,byagrantfromtheNewYorkStateEducationDepartment
Ph: 212-241-7655 Fax: 212-358-1059 Email: [email protected]
ParticipationConsentForm
DearParent:Yourson/daughter,_________________________________________,isparticipatinginaprogramattheIcahnSchoolofMedicineatMountSinai.Fromtimetotime,thestudentsmakevisitstootherinstitutionsforeducationalpurposes.Werequestyourconsentforyourchildtoparticipateintheseoff-campusexperiences.Pleaseindicateyourapprovalbysigningthebottomportionofthisletterandreturningitimmediatelytoouroffices.Ifyouhaveanyquestions,pleasecalltheprogramofficeat(212)241-7655or(212)241-6089.Sincerelyyours,AlysonDavis,LMSWProgramManagerIgivemyfullconsentformychild,_______________________________________,toparticipateinoff-campuseducationalexperienceplannedbytheMountSinaiCEYEProgram._____________________________________ _________________________Parent/Guardian(Print) Date_____________________________________ _________________________Parent/Guardian(Signature) Date
TheCenterforYouthEducation’sScienceandTechnologyEntryProgramanditsactivitiesaresupported,inwholeorinpart,byagrantfromtheNewYorkStateEducationDepartment
Ph: 212-241-7655 Fax: 212-358-1059 Email: [email protected]
PhotographyConsentForm
NameofStudent_________________________________________________________
Address________________________________________________________________
Age:__________(Ifparticipantisunder18yearsofage)
1. Iconsentthatastatementand/orphotographand/orvideoand/ormovieand/oraudiorecordingmaybetakenofmebyMountSinaiSchoolofMedicineand/orTheMountSinaiHospital(and/ortheiragents)regardingmypersonalandmedicalhistory,condition(s)andtreatment(s)atTheMountSinaiHospitaland/orbyitsstaffand/oraffiliatedphysicians,forthepurposesofpublicizing,promoting,marketingandadvertisingtheiractivities,programsandservices.
2. Igrantpermissionfortheabove-describedmaterial(s)tobedistributedtonewsmediaforpublicationand/orbroadcastand/ordistributionviaothermeanstothegeneralpublic.Irecognizethattheprecisemannerinwhichtheinformationandmaterial(s)willbeusedwillbedeterminesolelybysuchnewmediaandIthereforeacknowledgethatTheMountSinaiHospitalandMountSinaiSchoolofMedicine(collectively“MountSinai”)havenocontroloverorresponsibilityfortheuseofsuchinformationandmaterial(s)bythenewsmedia.
3. IfurthergrantpermissionforMountSinai,atitsoption,tousetheinformationandmaterial(s)asitseesfitinpublicationsandorproductionsofitsownmakinganddistribution.
4. IunderstandthatImaybeidentifiedbynameinconnectionwiththepublicuseoftheinformationandmaterial(s).
5. IherebyreleaseandagreetoindemnifyMountSinaianditsaffiliates,successorsandassignsandtheirrespectiveemployees,trusteesandagentsfromandagainstanyandallliability,includingreasonableattorneysfees,arisingoutoftheexerciseoftherightsgrantedbythisconsent.
Signature:_______________________________________________________Date:_____________________________(Participant,PersonalRepresentativeorLegalGuardian)
Witness:____________________________________PrintName:__________________________________________
PersonalRepresentativeorLegalGuardian:[PrintName]______________________________________