MiCA STEM and Health Careers Academy Summer Registration Form

Form Login Account (Optional)

INSTRUCTIONS

New Users CLICK HERE to setup your account for the "More in Common Alliance STEM and Health Careers Academy" 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 one (1) confidential recommendations on official school letterhead from a teacher or a counselor. Recommendation forms can be retrieved from the More in Common Alliance STEM and Health Careers Academy website and must be received directly by the recommender via mail or email by the deadline.

Inquiries regarding program information and the application process will be accepted beginning March 22nd. The application will be available for completion March 22- June 14 at 5:00 pm CST. All inquiries should be submitted to info@moreincommonalliance.org.

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 the More in Common Alliance STEM and Health Careers Academy 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.

APPLICANT INFORMATION

Last Name *

First Name *

Middle Initial

Student email *

Student date of birth * +

Current Grade Level *

Anticipated High School Graduation Year (for high school students only) *

Anticipated College Graduation Year (for college students only) *

Home Address *

Apartment, suite, or unit #

City *

State *

Zip code *

County of Residence *

Phone number *

Please indicate your T-shirt size *

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name 1 (First and Last) *

Mailing Address (if different than applicant) *

Apartment, suite, or unit #

City *

State *

Zip code *

Main Phone Number *

Cell Phone Number *

Email Address *

Highest Degree of Education *

Relationship to Applicant: *

Parent/Guardian Name 2 (First and Last) *

Mailing Address (if different than applicant) *

Apartment, suite, or unit #

City *

State *

Zip code *

Main Phone Number *

Cell Phone Number *

Email Address *

Highest Degree of Education *

Relationship to Applicant: *

ACADEMIC PROFILE

Name of School *

School Address *

School Address 2 *

City *

State *

Zip code *

County *

Current Cumulative GPA or Average

Please upload a copy of your most recent report card *

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 CONTACTS (other than parent/guardian)

Full Name *

Home Address *

City *

State *

Zip code *

Home Phone Number

Cell Phone Number *

Work Phone number *

Email Address *

Relationship *

add another

Name *

Phone number *

Relationship *

add another

Name *

Phone number *

Relationship *

ADDITIONAL INFORMATION

Citizenship *

Gender *

Race/Ethnicity *

Family Income *

Have you participated in any other summer pipeline or pathway programs? *

PHOTO: Please upload a recent photo of yourself. *

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

HEALTH CAREER INTEREST *

What sparked your interest in healthcare? What steps have you taken to explore the field of healthcare further? Please identify one learning experience that would greatly enhance your level of interest/understanding in healthcare? How will this learning experience benefit you in the future? *

The Academy offers opportunities to enhance critical thinking, collaboration and problem solving skills. Please share how you have demonstrated each of these skills as part of a school and/or work based project. *

Essay must have 300 word minimum; 500 word maximum

Or you can upload your essay below. Please attach your essay to state how you think this program will benefit you. *

STUDENT MEDICAL INFORMATION CONSENT FORM

First Name *

Last Name *

Middle Initial *

Address *

Home Phone *

Work Phone *

School *

Name of personal physician

Phone Number

In case of emergency contact *

Phone Number *

Special Diet Considerations *

List known allergies *

+-

List required medications *

+-

List current medical conditions *

+-

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

Medical Insurance Name *

Medical Insurance Policy Number *

Student Name *

Parent Name *

PHOTO, VIDEO, AND ARTWORK RELEASE I give the MiCA STEM and Health Careers Academy permission to use photographs taken of me (if over 18 years old) or my child and/or work my child has done as a part of the activities of the program. I hereby release the MiCA STEM and Health Careers 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 MiCA STEM and Health Careers Academy all rights, titles, and interest in any of the materials described above. *

I DO give the MiCA STEM and Health Careers Academy permission to use photographs or videos taken of my child and/or work my child has done.

I DO NOT give the MiCA STEM and Health Careers Academy permission to use photographs or videos taken of my child and/or artwork my child has done.

I am 18 years or older and DO give the MiCA STEM and Health Careers Academy permission to use photographs or videos taken of me and/or work I have done.

I am 18 years or older and DO NOT give the MiCA STEM and Health Careers Academy permission to use photographs or videos taken of me and/or work I have 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 MiCA STEM and Health Careers 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 MiCA STEM and Health Careers Academy, and anyone acting on behalf of the program, 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 MORE IN COMMON ALLIANCE STEM AND HEALTH CAREERS ACADEMY APPLICATION