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Stanford Institutes of Medicine Summer Research Program (SIMR

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PROGRAM DATES: JUNE 13- AUGUST 5, 2011 APPLICATION DEADLINE: February 25, 2011; Accepted students notified on April 8, 2011 Please read the Program Information document before you apply. Please print legibly (or preferably type), and keep a copy for your records

Personal Information: Name: ________________________________________________________________ Last First Middle Street Address: City, State, Zip Code: Home Phone #: ( ) Cell Phone #: ( ) Email Address: Gender: Male_____ Female_____ Date of Birth: _____________________ How old will be you on 6/13/11? ______ *Please note: You must be 16 years old or older by the program start date on June 13, 2011 to be eligible for the program AND you must be a junior or senior. *Please note: You must be a U.S Citizen or authorized to work for anyone in the U.S. to be eligible for the program.
Declaration of Tax Status: __ I am a U.S. Citizen __ I am a U.S. Permanent Resident (please attach a copy of the Permanent Resident Card-green card).

Parents/Guardian Information: Name: __________________________________________________________ Last First Middle Name: __________________________________________________________ Last First Middle Street Address: (if different from above) City, State, Zip Code: Phone Number: ( ) Email Address: Have your immediate family members (mother, father, siblings) attended college? ____yes ____no Parent or Guardian’s Education Level (highest degree attained): Mother/guardian: ____________________ Father/guardian: ___________________

please rank from 1-3 (with 1 being your first choice). Most Recent Cumulative GPA: weighted _________ .date taken/score(s): Have you applied previously to the SIMR Program? Yes _____ N o _____ If accepted. SAT I test scores are strongly encouraged for all applicants): SAT I. however.date taken/score(s): PSAT. Please see the Institute program descriptions in the Program Information document for more information. interests – please also list any positions held (circle years of involvement) 9 10 11 12 12 12 12 12 12 12 .High School Information: School currently attending: City.date taken/score(s): SAT II. internships. According to your research interest. unweighted _________ Test Scores. State: Expected year of graduation: ___ class of 2011 ___ class of 2012 IF you are NOT in the class of 2011 OR 2012. you are not eligible for the program. ___ Immunology ___ Cancer Biology (under-represented minority students are especially encouraged to apply) ___ Stem Cell Biology ___ Neuroscience ___ Cardiovascular Medicine ___ Digital Anatomy (new for summer 2011)—please see the information document for a description  How did you find out about the SIMR Program? __________________________ Please list any Honors and Awards (circle year that it was received) 9 10 11 9 10 11 9 10 11 9 10 11 9 10 11 9 10 11 Please list any extracurricular or community activities. if taken (please provide copies of test scores if available) (We don’t require any test scores.date taken/score(s): Other tests. will you require a parking permit? Yes _____ No _____ Will you be commuting by bus/train? Yes _____ No______ Race (For Statistical and Reporting Purposes only): Caucasian ____ African-American ____ Asian/Pacific Islander (please specify) ________________ Hispanic ____ Native American/Alaska Native ____ Other (please specify) _________ Decline to specify _____  The SIMR Program will enlist labs from 5 different Institutes within the School of Medicine.

work. ethnicity. race. how your participation in the program fits into your future educational and career objectives. Essay #2: At Stanford. gender. Essay #1: Please summarize the reasons that you are applying for the SIMR Program. we are committed to increasing the diversity (broadly defined) of students in the sciences and engineering. Your two essays combined should not exceed 2 double-spaced pages total (please use only 1 side of the paper).9 10 11 12 9 10 11 12 9 10 11 12 9 10 11 12 Please list any Honors or AP Courses taken (circle year it was taken) 9 10 11 12 9 10 11 12 9 10 11 12 9 10 11 12 9 10 11 12 9 10 11 12 Please list all the science and math courses you have completed or are currently taking and include the letter grade you have received per class: Course Name Received Grade Received Course Name Grade ESSAYS: Please answer the following two essays on a separate sheet of paper. class. and why you feel you are a good candidate for the program. hardships that you’ve faced or life experiences) would contribute to that diversity. ----------------------------------------------------------------------------------------------------------------------I certify that the information provided in this application is true and correct to the best of my knowledge. Please use font size 12 (Times New Roman or Arial). You may also discuss your institute/area of research preferences and personal goals. Please describe how your interests and background (in terms of culture. .

CA 94305-5166 . 2 essays previously described in the application (double-spaced. 2215A (Mail Code: 5166) Stanford.edu) All application materials including this checklist must be submitted in the SAME ENVELOPE (including the sealed letter of recommendation) to the following address: SIMR Program 269 Campus Drive West CCSR-Rm. The letter should be placed in a sealed envelope. A maximum of one (1) letter of recommendation from a science or math teacher who can accurately describe your academic potential. only one of them will be selected at random and opened. must be included in your application packet. A copy of your high school transcript (unofficial is acceptable). _____ 4. signed and dated on the back by the author. _____5. If more than one letter is sent. and included in your application packet. _____ 3. scientific knowledge. one side of the page only) _____6. Online registration (required) on our website (simr. the other will be discarded. interest in learning. Please give the teacher the letter of recommendation cover letter that is found on the following page. This cover letter must accompany the letter and should also be placed in the sealed envelope.Applicant’s Signature Date Parent/Guardian’s Signature Date SIMR 2011 APPLICATION CHECKLIST: Please provide the following additional materials to complete your application and mail in as a single packet: Checklist: _____1. and work ethic.stanford. A complete Application Form _____2. A copy of your SAT or PSAT scores (unofficial is acceptable) must be included in your application packet.

We will not accept applications before Feb. Are you aware of any hardships that may affect the student’s academic performance? How would you rank the applicant against other students in your course(s)? (check answer) ___Top 1% ___Top 5% ___Top 10% ___Top 25% ___Top 50% ___Bottom 50% ___Bottom 25% Please return your sealed letter of recommendation with this cover letter to the student applicant for inclusion in his/her complete application packet. 25. If you have any questions. Please note that application . have you known the applicant? How would you assess the student’s ability and interest in science? Do you feel the student demonstrates maturity and initiative? Please give any examples. 2011 APPLICATION DEADLINE: February 25. 2011. from diverse backgrounds. Your honest appraisal of this student and his/her potential to contribute to and benefit from participation in the summer program will be greatly appreciated. 2011 Recommendation Letter Cover Sheet Applicant Name:__________________________________________ Recommender Name:_______________________________________ Title:________________________________________Phone:_____________________ Address:_______________________________________________________________ Email:______________________________________ Dear Recommender: The Stanford Institutes of Medicine Summer Research Program is an 8-week summer program in which high school students. Please keep a copy of your letter of recommendation on file in the event the original is lost in the mail. and under what capacity. please address the following on a separate sheet of paper: • • • • • How long. please email: simr-program@stanford. 2010 in order to be eligible.edu. 2011. 25.AUGUST 5. and researchers on a research project. Feb. Applications must be postmarked (mailed at the post office) at the latest by Friday. Stanford Institutes of Medicine Summer Research Program (SIMR) PROGRAM DATES: JUNE 13. The application deadline is Feb. will be invited to learn how to do basic research while working closely with Stanford faculty. As you write your letter of recommendation. students. 1st .

edu if you have any questions. 25.materials must be postmarked by Feb. Signature________________________________________________Date___________ . Please email simr-program@stanford. 2011.