Ben Carson Pipeline Program Application
Form Login Account (optional)
New Users / Returning Users CLICK HERE to setup or return to your account for the "Morehouse School of Medicine Pipeline Programs Primary" application.  Creating an account enables you to 1) return to this application and your submitted results; 2) partially complete this application and return later to complete. The account you establish is only for this form.
INSTRUCTIONS

Please complete one application per applicant. Carefully review all instructions to complete the application, paying particular attention to application deadlines, program requirements and requests for supporting documents (e.g. transcripts, letters of reference) where applicable.

 
NOTE: Applications will not be considered final until all supplemental materials have been received.

NOTE: Any information you submit on this application will not be sold or passed along to a third party (see Morehouse School of Medicine's Privacy Statement).

NOTE: All questions marked with an * are required to consider the application complete.

NOTE: All data entered into the fields are automatically saved. 

Elementary & Middle School (Grades 4-8)
* Student Status
APPLICANT INFORMATION


PARENT/GUARDIAN INFORMATION
Relationship to applicant:
 

ACADEMIC PROFILE


EMERGENCY CONTACT (other than parent/guardian)

ADDITIONAL INFORMATION
* Age(s) of child(ren) in household
0/800 characters

 

 

 

 
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Science/Math Interest

As part of this application process, scores from standardized testing are needed. We ask that if you have the test scores available, that you complete the information below. If you do not have a copy of the scores please request the information from your child's school and mail it to: Morehouse School of Medicine Attn: Ben Carson Pipeline Program Hugh Gloster Building, Suite 104, 720 Westview Drive, SW, Atlanta, GA 30310

* Iowa Test of Basic Skills
 3rd Grade Scores5th Grade Scores8th Grade Scores
Math
Reading Comprehension
Grammar Usage
Science
Reference Skills

 
0/3000 words

 

Student Medical Information Consent Form

List known allergies
List required medications
Are we allowed to dispense sample medications. Please indicate which medications are approved.
Does the student wear contact lenses?
Does the student wear eye glasses?
* If the student needs immediate medical attention, do we have permission to take the student to the nearest medical facility for treatment?

The Ben Carson Science Academy at Morehouse School of Medicine (MSM) is working with young people to increase their interest in science and prepare them for careers in the health professions. As a part of this project, your child will participate in a variety of activities designed to enhance their science skills, teach them about different careers in health and science, and motivate them to pursue a career in the health professions. Please read BOTH the consent/releases below, initial and sign where indicated.

PARENTAL CONSENT and STUDENT ASSENT TO COMPLETE SURVEYS So that we can continue to improve how we teach and prepare our students, we would like to have students complete several surveys. In particular, your child will take surveys that assess the following: (1) their level of self-esteem, (2) their attitude toward science, and (3) their interest in and knowledge about science, health careers, and program impact. Each survey will be taken twice, once at the beginning of the project and once when the project is over. The information that we learn from these surveys will help us design better programs for students who show an interest in health and science. Your child's completion of any survey is totally voluntary. Your child's survey results will be held in confidence and utilized by an evaluation team for purposes of tracking the progress of participating children. Your child's name and any other identifying information will be removed from any broader publication of data from the surveys.

* PARENTAL CONSENT and STUDENT CONSENT TO COMPLETE SURVEYS
Student Assent
PHOTO, VIDEO, AND ARTWORK RELEASE I give the MSM Ben Carson Science Academy permission to use photographs taken of my child and/or work my child has done as a part of the activities of the program. I hereby release the Ben Carson Science Academy at MSM and anyone acting through the program or the school from any and all claims which I may have by reason of the publication of these photographs. I grant the Ben Carson Science Academy all rights, titles, and interest in any of the materials described above.
* In our efforts to ensure that the Ben Carson Science Academy is successful in impacting the post secondary achievement of the students we serve, we work in collaboration with colleges, universities and other educational agencies that track student enrollment data. This information gives the MSM an ability to report data, anonymously, about the students that matriculate through our programs and the rate of success the programs have on the ability to retain students in the medical and health professions.
* By signing this application, I certify to the statements and consents contained. The statements herein are true, complete and accurate to the best of my knowledge.
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Thank you for completing the Morehouse School of Medicine Ben Carson Pipeline Program Online Application. 
 
Morehouse School of Medicine
Pipeline Programs
720 Westview Drive SW
Atlanta, GA 30310
* Indicates Response Required