2012 MARC,IMSD,CAMP,UC LEADS Programs Application

Exit this survey

 

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1. First Name

First Name

2. MI

MI

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3. Last Name

Last Name

4. UCSC student #

UCSC student #

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5. UCSC College Affiliation

UCSC College Affiliation

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6. Last 4 digits of SS#

Last 4 digits of SS#

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7. Permanent (Home) Address:

Permanent (Home) Address:   Address
City
State
Zip
(Home) Phone#

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8. Current Address

Current Address   Address
City
State
Zip
(Current/Cell) Phone#

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9. Email

Email   UCSC Email :
Alternate Email:

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10. Racial or Ethnic Background (Check all that apply)

Racial or Ethnic Background (Check all that apply)   American Indian or Alaskan Native Asian/Non-filipino Filipino Black or African American Hispanic White or Caucasian Pacific Islander Other: (see question 11) I decline to state

11. If answered other for question 10 denote ethnicity

If answered other for question 10 denote ethnicity

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12. Gender:

Gender:

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13. Date of Birth:

Date of Birth:

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14. City and State or Country of Birth:

City and State or Country of Birth:

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15. Are you a US Citizen?:

Are you a US Citizen?:   Yes No

16. If not a US Citizen, are you a Permanent Resident.
*All four programs are funded by US goverment so we cannot financially support students who do not either have US citizenship or a permanent resident card. If you have an F1 or other Visa or you are not living legally in the US and you would still like support we still may have other ways to support you. Please contact the staff director.

If not a US Citizen, are you a Permanent Resident. *All four programs are funded by US goverment so we cannot financially support students who do not either have US citizenship or a permanent resident card. If you have an F1 or other Visa or you are not living legally in the US and you would still like support we still may have other ways to support you. Please contact the staff director.   Yes (If yes, send a copy of your resident card and social security card to our office) No

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17. EDUCATION

EDUCATION   Major:
Class Level Fall 2012:
Expected Date of Graduation:
Current Cumulative GPA:
Please Describe Your Future Education and Career Goals:
Are you a transfer student? if yes what school(s)?

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18. FAMILY BACKGROUND

	Didn't finish HS	High School	Some college	2yr College Grad	4yr College Grad	Post Grad Degree	Unknown	Deceased
Father:	*FAMILY BACKGROUND Father: Didn't finish HS	Father: High School	Father: Some college	Father: 2yr College Grad	Father: 4yr College Grad	Father: Post Grad Degree	Father: Unknown	Father: Deceased
Mother:	Mother: Didn't finish HS	Mother: High School	Mother: Some college	Mother: 2yr College Grad	Mother: 4yr College Grad	Mother: Post Grad Degree	Mother: Unknown	Mother: Deceased

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19. Fathers information

Fathers information   Father
Occupation

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20. Mothers information

Mothers information   Mother
Occupation

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21. Siblings

Siblings   How many siblings do you have?
How many are in college?

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22. List your Winter (2012) classes you are enrolled in:

List your Winter (2012) classes you are enrolled in:   Winter class 1:
Winter class 2:
Winter class 3:
Winter class 4:
Winter class 5:

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23. List your Spring (2012) classes you are enrolled in:

List your Spring (2012) classes you are enrolled in:   Spring class 1:
Spring class 2:
Spring class 3:
Spring class 4:
Spring class 5:

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24. Programs and activities in which you have participated (check all that apply):

Programs and activities in which you have participated (check all that apply):   None ACE ACCESS MEP RMI-CBSE Engineering Summer Bridge (thru MEP) RAD Bio 15 RAD Journal Club RAD Monday Seminars RAD Tutoring

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25. Other programs and activities in which you have participated not mentioned in question 24:

Other programs and activities in which you have participated not mentioned in question 24:   Other Program:
Other activity:

26. Are you currently working in a research lab on campus, if so which faculty member do you work with?

Are you currently working in a research lab on campus, if so which faculty member do you work with?

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27. ESSAYS QUESTION #1

Please type out your responses to the following questions. Please limit your
responses to 200 words for each question.

Please describe your personal background and what experience led you to where you are today in your education? Do not hesitate to express relevant extra curricular activities, and any interesting or unusual circumstances or obstacles in your personal or academic background.

ESSAYS QUESTION #1 Please type out your responses to the following questions. Please limit your responses to 200 words for each question. Please describe your personal background and what experience led you to where you are today in your education? Do not hesitate to express relevant extra curricular activities, and any interesting or unusual circumstances or obstacles in your personal or academic background.

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28. ESSAY QUESTION #2
Please describe what work experiences have you had that are related to UCSC, the sciences, research, or as a volunteer and what you feel you have learned from these experiences that make you a good candidate for the program.

ESSAY QUESTION #2 Please describe what work experiences have you had that are related to UCSC, the sciences, research, or as a volunteer and what you feel you have learned from these experiences that make you a good candidate for the program.

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29. ESSAY QUESTION #3
What are your long-range career aspirations after you obtain your bachelors degree? What career do you see yourself taking on? If you are unclear about a specific career, please share a number of possibilities you foresee for you in the future. How do you plan to reach these goals?

ESSAY QUESTION #3 What are your long-range career aspirations after you obtain your bachelors degree? What career do you see yourself taking on? If you are unclear about a specific career, please share a number of possibilities you foresee for you in the future. How do you plan to reach these goals?

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30. ESSAY QUESTION #4

Why would you like to be selected as a participant for the MARC, IMSD, CAMP and UC LEADS Programs? What do you hope to gain from it?

ESSAY QUESTION #4 Why would you like to be selected as a participant for the MARC, IMSD, CAMP and UC LEADS Programs? What do you hope to gain from it?

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31. We require two letters of recommendation, preferably from faculty.  We will however accept letters from program directors/coordinators, mentors, teaching assistants and former employers (Letters can be e-mailed to MARC.IMSD.CAMP.UCLEADS@gmail.com or send to MARC,IMSD,CAMP,UC LEADS MCD Biology Department).  Please list contact information for each or your recommenders below:

We require two letters of recommendation, preferably from faculty.  We will however accept letters from program directors/coordinators, mentors, teaching assistants and former employers (Letters can be e-mailed to MARC.IMSD.CAMP.UCLEADS@gmail.com or send to MARC,IMSD,CAMP,UC LEADS MCD Biology Department).  Please list contact information for each or your recommenders below:   Name:
Institution:
Email:
Name:
Institution:
Email:

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32. How did you hear about our program (please check all that apply):

How did you hear about our program (please check all that apply):   Flier Informational meeting ACE Visit to your class or study section UCSC faculty or staff member: Name and/or department Advisor: Name and/or department (see question 32) UCSC faculty or staff member: Name and/or department (see question 32) Other: (see question 32)

33. How did you hear about our program continued:

How did you hear about our program continued:   Advisor: Name and/or department:
UCSC faculty or staff member: Name and/or department:
Other:

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34. Do you receive financial aid?

Do you receive financial aid?   Yes (if yes, please e-mail to MARC.IMSD.CAMP.UCLEADS@gmail.com or drop box located in Thimann 377) No

35. Please submit all required documents in PDF format ( CV, Transcript, Financial Aid, Residency verification) to MARC.IMSD.CAMP.UCLEADS@gmail.com or drop box located by Thimann 377.

Note: Place your name and UCSC ID# in the e-mail subject heading.
(i.e. Diaz, Giovanni, 1234567)

Please submit all required documents in PDF format ( CV, Transcript, Financial Aid, Residency verification) to MARC.IMSD.CAMP.UCLEADS@gmail.com or drop box located by Thimann 377. Note: Place your name and UCSC ID# in the e-mail subject heading. (i.e. Diaz, Giovanni, 1234567)   I will e-mail all required documents to: MARC.IMSD.CAMP.UCLEADS@gmail.com I will submit all required documents through campus mail to: MARC,IMSD,CAMP, UC LEADS Programs MCD BIOLOGY I will submit all required documents to drop off box locate outside Thimann 377

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36. Certification
I certify that the information reported on this application, to the best of my knowledge, is true and correct. I authorize the MARC, IMSD, CAMP, UC LEADS staff and faculty to review my application in its entirety. If I am selected as a participant, I authorize UC Santa Cruz to publicize any relevant scholarship and biographical information and/or publish photographs. I also agree to participate in the assessment of MARC, IMSD, CAMP, UC LEADS programs by completing surveys and participating in focus groups and/or interviews regarding my perceptions and personal experiences in the program. I understand that all information will be treated as confidential by the researcher.

Certification I certify that the information reported on this application, to the best of my knowledge, is true and correct. I authorize the MARC, IMSD, CAMP, UC LEADS staff and faculty to review my application in its entirety. If I am selected as a participant, I authorize UC Santa Cruz to publicize any relevant scholarship and biographical information and/or publish photographs. I also agree to participate in the assessment of MARC, IMSD, CAMP, UC LEADS programs by completing surveys and participating in focus groups and/or interviews regarding my perceptions and personal experiences in the program. I understand that all information will be treated as confidential by the researcher.   I have read and understood the above passage and agree to the conditions stated above

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37. Please provide your electronic signature

Please provide your electronic signature

38. Date of application submission

	MM		DD		YYYY
.	Date of application submission   .   Month	/	Day	/	Year