Vivien Thomas Pipeline Program Application
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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.
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.

  • Completed Application
  • Report Card
  • Summary of Journal Article from Scientific American (APPLICANTS WILL RECEIVE THE WRITTEN ASSIGNMENT FOLLOWING COMPLETION OF THE APPLICATION WITH REQUIRED DOCUMENTS)
  • 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. Recommendations must be submitted directly by the recommender or your high school office by the April 18, 2015 postmark deadline.

Inquiries regarding program information, the application process and the mandatory writing assignment will be accepted beginning February 1. The application for the Vivien Thomas Summer Research program will be available for completion February 15- April 18. All inquries should be submitted to VTSRP@msm.edu.

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. 

* High School (Grades 9-10)
* Student Status
APPLICANT INFORMATION
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PARENT/GUARDIAN INFORMATION
Relationship to applicant:
 

ACADEMIC PROFILE


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

EMERGENCY CONTACT (other than parent/guardian)
* Relationship to applicant:
 

ADDITIONAL INFORMATION
0/800 characters

 

 
Have you presented an oral or poster presentation?
0/3000 words
Or you can upload your essay below.

 

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?
* PHOTO, VIDEO, AND ARTWORK RELEASE I give the MSM Vivien Thomas Summer Research 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 Vivien Thomas Summer Research Program 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 Vivien Thomas Summer Research Program all rights, titles, and interest in any of the materials described above.

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

Participants of the Vivien Thomas Summer Research Program 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 Vivien Thomas Summer Research Program at MSM, 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.
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Thank you for completing the Morehouse School of Medicine Vivien Thomas Pipeline Program application. 
 
Morehouse School of Medicine
Pipeline Programs
720 Westview Drive SW
Atlanta, GA 30310
* Indicates Response Required