TheCenterforYouthEducation’sScienceandTechnologyEntryProgramanditsactivitiesaresupported,inwholeorinpart,byagrantfromtheNewYorkStateEducationDepartment

Ph: 212-241-7655 Fax: 212-358-1059 Email: CEYE@mssm.edu

ScienceandTechnologyEntryProgramSUMMER2016APPLICATIONFORM

Date:________________ CurrentGradeLevel:_________OSISID#(9digitIDontranscript):_______________Program(s)ofinterest(pleaserank):1.2.3.DEMOGRAPHICDATA PrintName: First Middle Last HomeAddress: HouseNo./StreetName/Apt.No. City,State,ZipE-mailAddress:______________________HomePhoneNo:___________________________ CellPhoneNo:_______________________ FacebookName:___________________________ TwitterID:__________________________DateofBirth:______________________________ Gender:[]Male []FemaleNYStateResident:[]Yes[]No PlaceofBirth:_______________________ City/Town/CountryU.S.Citizen []Yes[]No PermanentResident:[]Date: VisaType: Ethnicity:(CheckOne)

ACADEMICDATA(Allapplicantsmustsubmittheirmostrecentreportcardortranscriptwiththisapplication)HighSchool:_______________________________________________________________________Address:__________________________________________________________________________GuidanceCounselor:____________________________Phone#:___________________________Doyoucurrentlyreceivefreeorreducedmealsatschool(documentationrequired)?☐YES☐NO

[]African-American/Black []Hispanic/Latino(specify)[]AmericanIndian/AlaskaNative []Other(pleasespecify)*

TheCenterforYouthEducation’sScienceandTechnologyEntryProgramanditsactivitiesaresupported,inwholeorinpart,byagrantfromtheNewYorkStateEducationDepartment

Ph: 212-241-7655 Fax: 212-358-1059 Email: CEYE@mssm.edu

STANDARDIZEDTESTSCORESPleaseanswerallthatapply–WriteN/Y/Tforanytests“NOTYETTAKEN”PSATVerbal__________ PSATMath__________________Datetaken___________SATIVERBAL________SATIMATH_________________Date/staken___________REG.MATH___________________Score_____________Date/staken_______________REG.SCI_______________________Score_____________Date/staken______________SATII:(SubjectName)___________________(Score)____________DateTaken____________SATII:(SubjectName)___________________(Score)____________DateTaken____________

GRADESFORLASTMARKINGPERIOD1.MathGPA__________ScienceGPA_________ CurrentOverallGPA_______(GradereportMUSTverify)2.WillyoubeinaRegentscurriculumin2015-2016?☐YES☐NO

MATHANDSCIENCECOURSESINSPRING2016Pleaseprovidecoursenumber/nameandindicateifitisaNonRegent(NR);Regent(R);orAdvancePlacement(AP)courseAlgebra____________________________ Biology___________________________________Geometry__________________________ Chemistry________________________________Pre-Calculus_______________________ Physics___________________________________ Calculus____________________________ OtherScience(name)___________________Trigonometry______________________OtherMath(name)_______________

PreviousMountSinaiProgram(s):_______________________________________________________________________________________________________________________________________________________________________________________________

TheCenterforYouthEducation’sScienceandTechnologyEntryProgramanditsactivitiesaresupported,inwholeorinpart,byagrantfromtheNewYorkStateEducationDepartment

Ph: 212-241-7655 Fax: 212-358-1059 Email: CEYE@mssm.edu

Pleaselistawardsreceivedinhighschool Pleaselistextracurricularactivities(school,community,church,involvementinotherprograms): Whatareyourcareerinterests?

FAMILYDATA StudentResidesWith[]MotherandFather[]Mother[]Father[]Other Mother/Guardian First&LastName HomePhoneNo.HomeAddress HouseNo./Street/Apt.No.,City,State,ZipEmailAddress WorkPhoneNo.

Father/Guardian First&LastName HomePhoneNo.HomeAddress HouseNo./Street/Apt.No.,City,State,Zip

EmailAddress WorkPhoneNo.

EmergencyContactName:___________________________________________________________________________________

EmergencyContactPhone#:_________________________________________________________________________________

TheCenterforYouthEducation’sScienceandTechnologyEntryProgramanditsactivitiesaresupported,inwholeorin

part,byagrantfromtheNewYorkStateEducationDepartment

Ph: 212-241-7655 Fax: 212-358-1059 Email: CEYE@mssm.edu

APPENDIXGUIDELINESFORSTUDENTELIGIBILITY

TheScienceandTechnologyEntryProgramisdesignedforstudentsattendingsecondaryschool(grades7-

12)inNewYorkStatewhoareeitherminoritieshistoricallyunderrepresentedinthescientific,technical,

healthrelatedandlicensedprofessions,oreconomicallydisadvantagedasdefinedbelow.ForthepurposeofSTEP,minoritieshistoricallyunderrepresentedinthescientific,technical,healthrelatedand

licensedprofessionsincluderesidentsofNewYorkStatewhoareAfricanAmerican,AmericanIndian/AlaskaNativeorHispanic.Ifyouareeconomicallydisadvantaged,youmaybeeligibleforSTEP.Please

refertotheguidelinesbelowandprovidetherequireddocumentation.

ForthepurposeofSTEP,astudentisconsideredaNewYorkStateresidentifheorsheresidesinNewYork

StateandhaslivedinNewYorkStateforthelasttwotermsofschoolpriortoentryintotheSTEPProgram,or

hasresidedinNewYorkStateforatleast12monthsimmediatelyprecedingthefirsttermforwhichheorshe

isseekingparticipationintheSTEPProgram.

The economic eligibility standards set forth in this Appendix apply only at the time of application to the

ScienceandTechnologyEntryProgram.Onceadmitted,aparticipantmaycontinuetoreceiveservices,even

ifthefamilyincomerisesabovethecurrenteligibilitystandards.

1. EconomicEligibilityCriteriaforFirst-TimeStudents

ForthepurposeofSTEP,astudentiseconomicallydisadvantagedifheorshemeetstheincomeeligibility

criteriaoutlinedinthetablebelow(economicdisadvantagedocumentationwouldbeacopyoftheparentor

legalguardian’ssignedmostrecentyear’staxreturns(IRSform1040,1040A,1040EZor4506).

Additionaldocumentationofhouseholdincomeneednotbecollectedtodetermineeligibilityundereconomicdisadvantageifthestudentfallsintooneofthefollowingcategories,anddocumentationisavailabletodemonstrate:

• Thestudent'sfamilyistherecipientoffamilyassistanceprogramaidorsafetynetassistance

throughtheNewYorkStateOfficeofTemporaryandDisabilityAssistanceoracountydepartment

ofsocialservices;oristherecipientoffamilyday-carepaymentsthroughtheNewYorkState

OfficeofChildrenandFamilyServicesoracountydepartmentofsocialservices;

• Thestudentislivingwithfosterparentsandnomoniesareprovidedfromthenaturalparents;or

• ThestudentisawardoftheStateoracounty.

• Thestudentreceivesfreeorreducedlunchathisorhersecondaryschool(verifiedbytheschool).

NumberinHouseholdDependingonIncome 2015-16

1

2

3

4

5

6

7

$21,755

$29,471

$37,167

$44,863

$52,559

$60,255

$67,951*

4Add$7,696foreachfamilymemberinexcessof7.

TheCenterforYouthEducation’sScienceandTechnologyEntryProgramanditsactivitiesaresupported,inwholeorinpart,byagrantfromtheNewYorkStateEducationDepartment

Ph: 212-241-7655 Fax: 212-358-1059 Email: CEYE@mssm.edu

2. Exceptions

Reference to the household income scale need not be made if the student falls into one of thefollowingcategoriesanddocumentationisavailable:

a. The student’s family is the recipient of (1) Family Assistance Program Aid, or (2) Safety NetAssistancethroughtheNewYorkStateOfficeofTemporaryandDisabilityAssistance,oracountyDepartment of Social Services, or (3) family day care payments through the New York StateOfficeofChildrenandFamilyServicesAssistance,oracountyDepartmentofSocialServices.

b. ThestudentisawardoftheStateoracounty.

3. Documentation

PleaseprovideonlyONEofthefollowingdocuments.

Thefollowingshallbeacceptabledocumentationofeconomiceligibility:

a. Preferred-Reducedorfreelunchdocumentationfromhighschoolorthestate.

b. Documentationofallincome,earneddividendsandinterest:asignedcopyofappropriateyear’staxreturn(IRSForms1040,1040A,1040EZ,or4506).

c. Documentation of a sole worker’s income from two or more employers: W2’s for theappropriateyearorsimilardocumentationacceptabletotheCommissioner.

d. Documentationofnoincome: acopyofIRSForm4506whichhasbeenfiledbythestudentorfamilywiththeInternalRevenueServiceoracopyofIRSLetter1722indicatingthatthestudentorparentdidnotfileareturn.

e. Documentation of pension, annuity, or unemployment benefits: letter from the applicableagency showing appropriate year’s total award (if not reported on IRS Forms 1040, 1040A,1040EZor1099).

f. Documentation of Social Security, Supplemental Security Income, or Veterans Administrationnon-educational benefits: a letter from the applicable agency showing applicable year’s totalawardforeachmemberofthehousehold, includingMedicarepremiumsorIRSForm1099foreachmemberofthehousehold.

g. Documentation of Social Services payments: verification from a branch of the State Office ofTemporary and Disability Assistance, Office of Children and Family Services Assistance, or acounty department of Social Services showing year that benefitswere received and names ofrecipientsincludingtheapplicant.

h. Documentationofchildsupportand/oralimony:acourtorder,affidavit.

i. Documentation of additional members in household: birth certificates, marriage certificates,third-party verification, or similar documentation acceptable to the Commissioner, alongwithproofofincomeorlackofincomeforeachsuchmember.

4. OSISIDNYCDOEOSISnumberisanine-digitnumberthatisissuedtoallstudentswhoattendaNewYorkCitypublicschool.ThenumbercanbefoundonyourIDcardortranscript.

TheCenterforYouthEducation’sScienceandTechnologyEntryProgramanditsactivitiesaresupported,inwholeorinpart,byagrantfromtheNewYorkStateEducationDepartment

Ph: 212-241-7655 Fax: 212-358-1059 Email: CEYE@mssm.edu

MedicalCertificationForm

Student’sName:______________________________________________________ Last4digitsofSocialSecurity_________ Last First(___)Ihaveexaminetheabovenameson,_____________andfoundhim/hertobemedicallyfitandcapableofperformingallassignedduties.(___)Theabovenamedhasaconditionthatwillaffecthis/herabilitytofunctioneffectivelyandmayputothersatrisk(pleasedescribethecondition):Immunizations:1. P.P.D. Negative___________ Positive___________

DateGiven___________ DateRead___________

[IftestisfoundtobepositivepleaseattachChestX-Ray.PPDmustbewithinthelast6months.StudentswithaPPDconversioninthelast12monthmustshowproofoftreatmentandprovideaChestX-Ray.]

2. M.M.R.orTiter* Dates_______________________*Immune___________NotImmune____________Datetested_____________

3.HepatitisB Dates_____________________________________4.TDaP Date____________5.Varicella Dates____________ ______________6.Asthma Yes__________ No________________________________________________________________________________________________________Physician’sName(Print) Address_____________________________________________________________________________________________Physician’sSignature City/State/Zip_____________________ _______________________________________________________________Date Telephone

TheCenterforYouthEducation’sScienceandTechnologyEntryProgramanditsactivitiesaresupported,inwholeorin

part,byagrantfromtheNewYorkStateEducationDepartment

Ph: 212-241-7655 Fax: 212-358-1059 Email: CEYE@mssm.edu

MedicalAttentionConsentForm

DearParent:

Weaskyourpermissiontoextendmedicalattentiontoyourson/daughter–asaparticipantintheMount

SinaiCEYEProgram–shouldanemergencyarise.

PleaseindicateyourconsentfortheHospitaltotreatyourchildincaseofanemergency,bycompleting

andsigningthebottomportionofthisletter–andreturningitimmediatelytotheprogramoffice.A

chargeforthisservicemayapply.

Sincerelyyours,

AlysonDavis,LMSW

ProgramManager

IgivepermissiontoTheMountSinaiHospitaltoextendmedicalattentionandtreatmenttomy

child,_______________________________________________shouldanemergencyariseduringthehoursthathe/she

isinattendanceattheMountSinaiCEYEProgram.

MedicaidNo./Type____________________ __________________________

OrOtherInsurance____________________ Parent/Guardian(Print)

ExpirationDate____________________

__________________________

Parent/Guardian(Signature)

__________________________

Date

TheCenterforYouthEducation’sScienceandTechnologyEntryProgramanditsactivitiesaresupported,inwholeorinpart,byagrantfromtheNewYorkStateEducationDepartment

Ph: 212-241-7655 Fax: 212-358-1059 Email: CEYE@mssm.edu

ParticipationConsentForm

DearParent:Yourson/daughter,_________________________________________,isparticipatinginaprogramattheIcahnSchoolofMedicineatMountSinai.Fromtimetotime,thestudentsmakevisitstootherinstitutionsforeducationalpurposes.Werequestyourconsentforyourchildtoparticipateintheseoff-campusexperiences.Pleaseindicateyourapprovalbysigningthebottomportionofthisletterandreturningitimmediatelytoouroffices.Ifyouhaveanyquestions,pleasecalltheprogramofficeat(212)241-7655or(212)241-6089.Sincerelyyours,AlysonDavis,LMSWProgramManagerIgivemyfullconsentformychild,_______________________________________,toparticipateinoff-campuseducationalexperienceplannedbytheMountSinaiCEYEProgram._____________________________________ _________________________Parent/Guardian(Print) Date_____________________________________ _________________________Parent/Guardian(Signature) Date

TheCenterforYouthEducation’sScienceandTechnologyEntryProgramanditsactivitiesaresupported,inwholeorinpart,byagrantfromtheNewYorkStateEducationDepartment

Ph: 212-241-7655 Fax: 212-358-1059 Email: CEYE@mssm.edu

PhotographyConsentForm

NameofStudent_________________________________________________________

Address________________________________________________________________

Age:__________(Ifparticipantisunder18yearsofage)

1. Iconsentthatastatementand/orphotographand/orvideoand/ormovieand/oraudiorecordingmaybetakenofmebyMountSinaiSchoolofMedicineand/orTheMountSinaiHospital(and/ortheiragents)regardingmypersonalandmedicalhistory,condition(s)andtreatment(s)atTheMountSinaiHospitaland/orbyitsstaffand/oraffiliatedphysicians,forthepurposesofpublicizing,promoting,marketingandadvertisingtheiractivities,programsandservices.

2. Igrantpermissionfortheabove-describedmaterial(s)tobedistributedtonewsmediaforpublicationand/orbroadcastand/ordistributionviaothermeanstothegeneralpublic.Irecognizethattheprecisemannerinwhichtheinformationandmaterial(s)willbeusedwillbedeterminesolelybysuchnewmediaandIthereforeacknowledgethatTheMountSinaiHospitalandMountSinaiSchoolofMedicine(collectively“MountSinai”)havenocontroloverorresponsibilityfortheuseofsuchinformationandmaterial(s)bythenewsmedia.

3. IfurthergrantpermissionforMountSinai,atitsoption,tousetheinformationandmaterial(s)asitseesfitinpublicationsandorproductionsofitsownmakinganddistribution.

4. IunderstandthatImaybeidentifiedbynameinconnectionwiththepublicuseoftheinformationandmaterial(s).

5. IherebyreleaseandagreetoindemnifyMountSinaianditsaffiliates,successorsandassignsandtheirrespectiveemployees,trusteesandagentsfromandagainstanyandallliability,includingreasonableattorneysfees,arisingoutoftheexerciseoftherightsgrantedbythisconsent.

Signature:_______________________________________________________Date:_____________________________(Participant,PersonalRepresentativeorLegalGuardian)

Witness:____________________________________PrintName:__________________________________________

PersonalRepresentativeorLegalGuardian:[PrintName]______________________________________