1. Gifted Student Near-Peer Internship Application

Dear Gifted Student and Parents,
Thank you for your interest in our Near-Peer Internship Program for Gifted High School and College Students. Please take a moment to answer all of the questions on this application form. Students under the age of 18 must provide parental information where it is requested on the application and must obtain parental permission.
I look forward to working with you,
Dr.Demetrikopoulos

Melissa K. Demetrikopoulos, Ph.D.
Director of Scientific Communications
Chair, Division of Program Development and Assessment
Institute for Biomedical Philosophy
GiftedInfo@BioPhi.org

* 1. For the following questions please provide the information requested. Please provide the student's permanent address.

* 2. Please answer the following question with the Month Day and Year.

Date of Student's birth
/
/

* 3. Gender

* 4. Please indicate type of gifted program that you participate(ed) in during the school year (mark as many as apply).

* 5. Current Grade Level (2009-2010 school year)

* 6. Please Indicate your GPA for THE MOST RECENT 3 YEARS. Include this current year if you have gotten any report cards thus far. Please convert all grades to a 4 point scale. Thus, all A's are worth 4 points regardless of AP or other status. Also, for schools that do not give grades in the early years, please convert the grades such that the highest option is a 4.

  3.5-4.0 3.0-3.49 2.5-2.99 2.0-2.49 1.5-1.99 1.0-1.49 0.0-0.99
6
7
8
9
10
11
12
College Freshman
College Sophomore
College Junior
College Senior
Other College

* 7. Please mark all of the courses below that you took in middle school (Grades 5-8).

  Honors/Advanced Pre-AP AP IB
Biology
Chemistry
Physics
Calculus
Statistics
Psychology

* 8. Please mark all of the courses below that you took in high school.

  Honors AP IB
Biology
Chemistry
Physics
Calculus
Statistics
Psychology

* 9. Please indicate any academic competitions that you have been involved with in the past 3 years. Please mark Participation for any event in which you did not earn first place even if you received another award. Please try to choose the closest category to the competition in which you participated even if it is not an exact match.

  2010 2009 2008
Science Fair Participation
Science Fair 1st Place
Other Science Competition Participation
Other Science Competition 1st Place
Engineering or Robotics Competition Participation
Engineering or Robotics Competition 1st Place
Math Competition Participation
Math Competition 1st Place
Reading Competition Participation
Reading Competition 1st Place
Writing Competition Participation
Writing Competition 1st Place
History Competition Participation
History Competition 1st Place
Social Studies Competition Participation
Social Studies Competition 1st Place
Spelling Competition Participation
Spelling competition 1st Place

* 10. Please list your relevant extracurricular activities. You may ALSO send a copy of your full cv or resume if you have one to GiftedInfo@BioPhi.org.

* 11. In 3-5 sentences, please tell us what you hope to gain by participating in this Near-Peer Internship Opportunity.

* 12. In 3-5 sentences, please tell us what you think you can contribute during your Near-Peer Internship.

* 13. t-shirt size

* 14. Does you have any physical, dietary, or other special needs? Please let us know if you have any special needs. The internship, as designed, requires a great deal of physical activity. We are willing to work with individuals who wish to participate but who may need modifications to the format. Please contact us ASAP if this applies. We fully comply with the Americans with Disabilities Act.

* 15. Do any special arrangements need to be made for you? Please let us know if you have any special needs. The internship, as designed, requires a great deal of physical activity. We are willing to work with individuals who wish to participate but who may need modifications to the format. Please contact us ASAP if this applies. We fully comply with the Americans with Disabilities Act.

* 16. Please provide the following information. Please do not leave the questions blank and respond with none if there is no other response.

* 17. How did you hear about the program? Please mark as many as apply.

* 18. I recognize that the program's activities, which may include a variety of physical activities both indoors and outdoors, could involve risk of physical injury or illness, and I assume the risks associated with these activities, knowing that despite precautions and supervision, not all risks can be prevented. Additionally, I give consent for the use of my photograph for educational purposes and promotion. I have/will have read the full Informed Consent Agreement and Assumption of Risk form and will provide a signed copy prior to my participation in the program. (A full copy can be requested from GiftedInfo@BioPhi.org and it will be posted on the website soon.) If I am under age 18 I will also provide a copy signed by my parents.

* 19. Is there any other important information that we should know?

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