Submit all applications materials by: January 15, 2015
Incomplete or late applications will not be considered

Mailing: Science Apprenticeship Program

Monell Chemical Senses Center

3500 Market Street

Philadelphia, PA 19104-3308

Email:

(put “MSAP 2015 App” in the subject line)

Fax: 215-573-0909 (ATTN: MSAP)

APPLICATION CHECK LIST: r Completed MSAP application r Letter of recommendation r Personal statement

APPLICANT INFORMATION

Applicant Name:

Mailing Address:

City State Zip Code

Home Phone (with area code): Cell phone (with area code):

E-mail address:

Are you a resident of (check one): r Philadelphia r Camden, NJ Sex: r Female r Male r Prefer not to respond

Are you the first generation in your family planning to attend college? r Yes r No

Parent/Guardian's Name:

Parent/Guardian’s Email: Cell phone (with area code):

The MSAP’s mission is to foster interest in science careers among those typically under-represented in the sciences. Please check all that apply to you:

r Black/African American r White/Caucasian r Hispanic/Latino r Asian/Asian Pacific

r American Indian /Alaskan Native r Native Hawaiian/ Pacific Islander r Other:

Does your family meet the income eligibility requirements for reduced-price lunch under the National School Lunch Program? (For more information or to determine your eligibility status, visit http://www.ellistrust.org/#income). r Yes r No r Not Sure

ACADEMIC INFORMATION

Current High School:

Location (City, State):

Current Year (circle one): 9 10 11 12 Expected Year of Graduation:

If you plan to attend college, where will you apply?

Indicate the grades you received in the following courses: (If you have not had a class in one of these areas, write N/A in that box.)

Course Topic / Biology / Chemistry / Psychology / Algebra / Other Math Course / Other Science Course
Course Name
Grade Received

What is your favorite math and/or science course and why?

RECOMMENDATION INFORMATION

Please indicate the individual from your school who will be sending a letter of recommendation on your behalf:

Name:

Office phone (with area code): E-mail:

ACTIVITIES INTERESTS

What type(s) of research are you most interested in? (Check all that apply):

r Chemistry r Biology r Physics r Psychology r Animal Studies r Human Studies r Cellular Studies r Nutrition r Unsure/No preference

Please review the faculty profiles at www.monell.org/faculty and identify research topics and methodologies that are of interest to you.

What are your anticipated career plans?

r Research rMD/PhD r Medical School r Unsure rOther:

List any extracurricular, volunteer, community, and family activities in the order of their interest to you:

If applicable, list the names of any past employers and describe your job responsibilities:

Name of Employer / Dates of Employment / Key Responsibilities

PERSONAL STATEMENT

On a separate sheet of paper, please describe in an essay (one page total, typed):

Yourself and why you have chosen to apply to the Monell Science Apprenticeship Program, and

Your short and long term career goals

How did you hear about MSAP? r School r Family/Friend r Internet r Ellis Trust r WINS

rOther: