Exit this survey 2012 MARC,IMSD,CAMP,UC LEADS Programs Application 1. Default Section Question Title * 1. First Name Question Title * 2. MI Question Title * 3. Last Name Question Title * 4. UCSC student # Question Title * 5. UCSC College Affiliation Question Title * 6. Last 4 digits of SS# Question Title * 7. Permanent (Home) Address: Address City State Zip (Home) Phone# Question Title * 8. Current Address Address City State Zip (Current/Cell) Phone# Question Title * 9. Email UCSC Email : Alternate Email: Question Title * 10. 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 Question Title * 11. If answered other for question 10 denote ethnicity Question Title * 12. Gender: Question Title * 13. Date of Birth: Question Title * 14. City and State or Country of Birth: Question Title * 15. Are you a US Citizen?: Yes No Question Title * 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. Yes (If yes, send a copy of your resident card and social security card to our office) No Question Title * 17. 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)? Question Title * 18. FAMILY BACKGROUND Didn't finish HS High School Some college 2yr College Grad 4yr College Grad Post Grad Degree Unknown Deceased Father: 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 Question Title * 19. Fathers information Father Occupation Question Title * 20. Mothers information Mother Occupation Question Title * 21. Siblings How many siblings do you have? How many are in college? Question Title * 22. List your Winter (2012) classes you are enrolled in: Winter class 1: Winter class 2: Winter class 3: Winter class 4: Winter class 5: Question Title * 23. List your Spring (2012) classes you are enrolled in: Spring class 1: Spring class 2: Spring class 3: Spring class 4: Spring class 5: Question Title * 24. 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 Question Title * 25. Other programs and activities in which you have participated not mentioned in question 24: Other Program: Other activity: Question Title * 26. Are you currently working in a research lab on campus, if so which faculty member do you work with? Question Title * 27. ESSAYS QUESTION #1Please type out your responses to the following questions. Please limit yourresponses 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. Question Title * 28. ESSAY QUESTION #2Please 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. Question Title * 29. ESSAY QUESTION #3What 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? Question Title * 30. ESSAY QUESTION #4Why 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? Question Title * 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: Name: Institution: Email: Name: Institution: Email: Question Title * 32. 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) Question Title * 33. How did you hear about our program continued: Advisor: Name and/or department: UCSC faculty or staff member: Name and/or department: Other: Question Title * 34. 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 Question Title * 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) 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 Question Title * 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. I have read and understood the above passage and agree to the conditions stated above Question Title * 37. Please provide your electronic signature Question Title * 38. Date of application submission . Date Done