MSM STEAM ACADEMY (4-8) 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) *

MSM Fall STEAM Academy

MSM Spring STEAM Academy

MSM Summer STEAM Academy

Student Status *

New

Returning

APPLICANT INFORMATION

Current Education Level *

Returning Science Academy Applicants Year: *

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 *

OTHER ADDRESS (if different from above)

City

State

Zip Code

Home Telephone *

Cellular Telephone

Email Address

PARENT/GUARDIAN INFORMATION

Mother's Name *

Mailing Address *

City *

State *

Zip Code *

Home Phone *

Work Phone *

Cellular Phone *

E-mail Address *

Highest degree of education *

Employer *

Father's Name *

Mailing Address *

City *

State *

Zip Code *

Home Phone *

Work Phone *

Cellular Phone *

Mailing Address *

Employer *

Job Title *

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 *

Employer *

Job Title *

E-mail Address *

Highest degree of education *

ACADEMIC PROFILE

Name of School *

Address *

Address 2

City *

State *

Zip Code *

County *

EMERGENCY CONTACT (other than parent/guardian)

Full Name *

Relationship to applicant *

Home Address *

City *

State *

Zip Code *

Home Phone *

Work Phone *

Cellular Phone *

E-mail Address *

ADDITIONAL INFORMATION

Citizenship *

Gender *

Race *

Ethnicity *

Family income *

Number of family members in household *

Age(s) of child(ren) in household *

+-

Have you participated in any MSM Pipeline Programs? *

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

0/800 characters

PHOTO: Please upload a recent photo of yourself. *

Please submit a copy of your most recent report card *

Please upload your letter of recommendation *

Rising Grade Level *

Current Math Grade *

Current Science Grade *

Anticipated High School Graduation Year: * +

Anticipated College Graduation Year: * +

Science/Math Interest

How interested are you in studying science/math? *

Health Career 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: MSM STEAM Academy-Educational Outreach and Health Careers Office,720 Westview Drive, SW, Atlanta, GA 30310

GA Milestones *

	3rd Grade Scores	5th Grade Scores	8th Grade Scores
Math	3rd Grade Scores	5th Grade Scores	8th Grade Scores
Reading Comprehension	3rd Grade Scores	5th Grade Scores	8th Grade Scores
Science	3rd Grade Scores	5th Grade Scores	8th Grade Scores
Language Arts	3rd Grade Scores	5th Grade Scores	8th Grade Scores

Please submit a copy of our most recent standardized test scores.

New students are required to submit a one page essay. The essay topics are listed below by grade level. 4th and 5th Graders: What are the reasons I want to participate in the MSM STEAM Academy? 6th, 7th and 8th Graders: Why is it important to be scientifically literate in today's society?

0/3000 words

You may also attach your writing sample

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 *

The MSM STEAM Academy 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 *

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

PHOTO, VIDEO, AND ARTWORK RELEASE I give the MSM STEAM 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 MSM STEAM Academy 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.

In our efforts to ensure that the MSM STEAM 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 STEAM Academy 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. *

I DO give MSM and the MSM STEAM Academy permission to obtain postsecondary enrollment information of current or former participants.

I DO NOT give MSM and the MSM STEAM Academy permission to obtain postsecondary enrollment information of current or former participants.

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 Morehouse School of Medicine MSM STEAM Academy Online Application.

Morehouse School of Medicine
Office for Educational Outreach and Health Careers
720 Westview Drive SW
Atlanta, GA 30310

404-752-1590

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