MSM STEAM Academy (9-12) Application

INSTRUCTIONS

Form Login Account (optional)

New Users / Returning Users CLICK HERE to setup or return to your account for the "Morehouse School of Medicine Pipeline Program" 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.

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.

Completed Application
Report Card
Completed Medical Information Consent Form
Recommendation Letters: Request two (2) confidential recommendations on official school letterhead from teachers and/ or a counselor, including at least one from a science teacher if only if you are applying for the 6-week summer research program. Recommendation forms can be retrieved from the MSM STEAM Academy 9-12 website and must be received directly by the recommender or your high school office via mail or email by the March 21, 2025, deadline.

Inquiries regarding program information and the application process will be accepted beginning February 3rd. The application for the MSM STEAM Academy (9-12) program will be available for completion from February 3 - March 21 at 5:00 pm. All inquries should be submitted to ryanclark@msm.edu and adansby@msm.edu.

Please check all sessions you are interested in attending. The 3-week session may be cancelled if a minimum number of participants is not met.

NOTE: Applications to programs that require supplemental materials will not be considered final until all 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.

Student Status *

New

Returning

What program did you participate in? *

Which high school (Grades 9-12) Program are you interested in? *

MSM STEAM Academy (9-12) Option 2 (6 week) Early June- Mid July

MSM STEAM Academy (9-12) 3-week Session Early June-Late June

APPLICANT INFORMATION

Anticipated High School Graduation Year *

Current Grade *

Current Age *

Last Name *

First Name *

Middle Initial

Date of Birth (ex. 01/01/1997) *

Social Security Number *

MAILING ADDRESS *

City *

State *

Zip Code *

County of residence *

Home Telephone *

Cellular Telephone

Email Address *

OTHER ADDRESS (if different from above)

City

State

Zip Code

PARENT/GUARDIAN INFORMATION

Mother's Name (First and Last) *

Mailing Address (if different than applicant)

City

State

Zip Code

Home Phone

Work Phone

Cellular Phone

E-mail Address *

Highest degree of education

Father's Name (First and Last) *

Mailing Address (if different from applicant)

City

State

Zip Code

Home Phone

Work Phone

Cellular Phone

E-mail Address *

Highest degree of education

Guardian's Name

Relationship to applicant:

Grandparent

Aunt

Uncle

Other Other

Mailing Address

City

State

Zip Code

Home Phone

Work Phone

Cellular Phone

E-mail Address

In an effort to provide resources & support to our students and parents, we would like to know if you, as a parent/guardian are interested in parent coaching and support? *

ACADEMIC PROFILE

Name of School *

Address *

Address 2

City *

State *

Zip Code *

County *

Current Cumulative GPA *

Test Scores (if applicable). If you have not taken the SAT or ACT, please skip this item.

SAT

Verbal

Math

Writing

ACT

English

Math

Science

Reading

Writing (optional)

EMERGENCY CONTACT (other than parent/guardian)

Full Name

Relationship to applicant:

Guardian

Other Other

Home Address

City

State

Zip Code

Home Phone

Work Phone

Cellular Phone

E-mail Address

ADDITIONAL INFORMATION

Citizenship *

Gender *

Ethnicity *

Family income *

Have you participated in any other summer pipeline programs (non-MSM)? *

If your response was "yes," which programs have you participated in?

0/800 characters

PHOTO: Please upload a recent photo of yourself. *

SCIENCE/MATH INTEREST: How interested are you in studying science/math? *

HEALTH CAREER INTEREST: *

Please submit a copy of your most recent report card *

Have you presented an oral or poster presentation? *

Yes

No

At what level did you present?

School Session

Year

Grade Level

Title of Science Project

Please write an essay below to state how you think program will benefit you.

0/3000 words

Or you can upload your essay below.

Please attach your essay to state how you think this program will benefit you.

Letter describing why you are interested in laboratory research and what area of research you find most interesting. *please look at our website to familiarize yourself with the type of research that is done at Morehouse School of Medicine* *

0/3000 words

Or you can upload your essay below.

Attach a letter describing why you are interested in laboratory research and what area of research you find most interesting. *please look at our website to familiarize yourself with the type of research that is done at Morehouse School of Medicine*

Student Medical Information Consent Form

First Name *

M.I.

Last Name *

Address

Home Phone

Work Phone

School

Name of personal physician *

Phone:

In case of emergency contact:

Phone

Special Diet considerations

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?

Yes

No

Does the student wear eye glasses?

Yes

No

List current medical condition(s)

If the student needs immediate medical attention, do we have permission to take the student to the nearest medical facility for treatment? *

Yes

No

Medical Insurance Name *

Medical Insurance Policy number

Student Name *

Parent Name *

PHOTO, VIDEO, AND ARTWORK RELEASE I give the MSM STEAM Academy (9-12) Program 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 MSM STEAM 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 MSM STEAM Academy all rights, titles, and interest in any of the materials described above. *

I DO give the MSM STEAM Academy permission to use photographs or videos taken of my child and/or work my child has done.

I DO NOT give the MSM STEAM Academy permission to use photographs or videos taken of my child and/or artwork my child has done.

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 *

I DO give my child permission to complete the surveys described above.

I DO NOT give my child permission to complete the surveys described above.

Student Assent

I DO understand what I have read and I agree to complete the surveys that have been described

I DO NOT understand what I have read and I agree to complete the surveys that have been described

Participants of the MSM STEAM Academy will be working in a biomedical laboratory. They will be conducting laboratory experiments that may involve the use of live cultures, laboratory animals and chemicals. Each student will be involved in an extensive laboratory safety-training workshop before entering a laboratory setting. I hereby release the MSM STEAM Academy, and anyone acting on behalf of the program or the school, from any and all claims which may result in negligence. (the student and parent signatures are required)

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. *

I agree

I disagree

Student Name *

Parent Name *

Date * +

Thank you for completing the MSM STEAM Academy application.

Morehouse School of Medicine
MSM STEAM Academy
720 Westview Drive SW
Atlanta, GA 30310

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