AS&S FINAL Candidate Application Form: Nepal

......................................CONTACT INFORMATION.......................................





Suggestion:
For each question candidate should enter the exact information and some of the fields in this section may have to be re-entered, e.g. School Name. In order to facilitate the process, consider using a text editor to contain the repeated information. Then use copy and paste to enter the repeated information into the appropriate fields.

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* 1. Your Full Name

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* 2. What is your Gender

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* 3. Your Marital Status. (State whether single, married or specify if other)

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* 4. Your Age & Date of Birth(DOB) (in Yrs.).

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* 5. Please provide your Email Address.

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* 6. Candidate's Membership in AS&S
If currently a member of ASS, what is your Entering Year?

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* 7. If currently a member of AS&S, what email address has been assigned to you?
Note: Your email will end with @asciencesociety.org

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* 8. Please enter your Institute Name and Address

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* 9. Please enter your residential address

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* 10. Please enter your contact address (If Different from your Residential address)

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* 11. Candidate's Phone Number (Land Line & Mobile Phone)

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* 12. Your Father's/local Guardian's Name, Address, Email and Phone information

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* 13. Please provide Emergency Contact's Full Name

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* 14. Your Emergency Contact Information

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* 15. Please provide the following

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* 16. Candidate's Grade Level/Rank/Class/Percentage of marks obtained in the current or last Exam/Assessment.

......................................CANDIDATE DEMOGRAPHIC INFORMATION.......................................

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* 17. Please provide the name of Region and Zone where you were Born

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* 18. Please provide name of the Region and Zone where your Mother were Born

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* 19. Please provide name of the Region and Zone where your Father were Born

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* 20. For How many years are you living in Nepal

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* 21. What is your Mother tongue/Native language

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* 22. What is your Ethnicity?

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* 23. Besides English, list other languages you know

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* 24. Provide your family's and/ or Your Citizenship Number

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* 25. Current Educational Status

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* 26. Your Education Type/Mode

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* 27. Current Class/Standard if in High Secondary School(HSS) or below.

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* 28. What is the name of your School/College/University/Institute

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* 29. Enter your School/College/University/Institute address

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* 30. Please enter your current rank and/or Percentage of marks in your present or last exam/assessment

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* 31. Provide the list of your Major,Minor and other allied/subsidiary subjects/Research theme.

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* 32. Scholarships/Prizes/Awards won and details:

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* 33. If previously transferred, which School/College/University/Institute did you transfer from?

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* 34. Which University Did you graduate from (If Applicable)

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* 35. Name and contacts of your recommender for AS&S internship (if you remember):

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* 36. If you graduated from College/University, what Month/Year did you graduate?

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* 37. If you have graduated from College/University, what is your current status?

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* 38. To what major Religion do you belong?

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* 39. What is your Present Family status
(State whether APL (Above Poverty Line or Below Poverty Line)

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* 40. Are You or Your family members being covered under any insurance scheme, please specify the Type of Insurance Scheme you are involved into Select all that apply. (Tick the appropriate one)

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* 41. Your Household's total or gross Annual Income

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* 42. How many members are there in your Family (include yourself)?

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* 43. How many Siblings

......................................CANDIDATE ACADEMIC INFORMATION.......................................

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* 44. Are your Siblings Educated; if yes please specify at which Level

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* 45. Would you be the FIRST in your family to finish (Tick mark all that apply)

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* 46. What Extracurricular activities are you interested in?

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* 47. What are your two highest Career Choices?

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* 48. Indicate your Proficiency/Preference/Comfort Level (Mention your levels as High, Average or Low)

  Proficiency Level Preference Level Comfort Level
Zoology
Social Science
Physics
Mathematics
Earth Science
Chemistry
Botany
Biological & Life Sciences

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* 49. Choice for your area of research:
In order to best match you with a mentor, please indicate your First (1st), Second (2nd), Third (3rd), Fourth (4th) and Fifth (5th) preferences.

  Highest - First Second Third Fourth Lowest - Fifth
Agriculture & Natural Resources
Astronomy
Architecture & Environmental Design
Atmospheric Science
Computer Science
Engineering
Bio/Informatics
Biotechnology
Ecological Science
Environmental Science
Medical Sciences
Epidemiology
Statistics
Robotics
Anthropology
Psychology
Science Reporting/ Writing
Science Advocacy
Legal Science (Patent Law, etc.)
Forensic Science
Communications
Linguistic Sciences
Library Science
Nutritional Science
Health Professions
Actuarial Science
Social Sciences
Botanical Sciences
Animal Husbandry
Veterinary Medicine
Complementary Medicine (Naturopathy, Chiropractic, Herbalism, Traditional Chinese Medicine, Unani, Ayurveda, Medicine, Yoga, Biofeedback, Hypnosis, Homeopathy, Acupuncture, Nutritional based therapies, etc.)

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* 50. What are your long term career goals?

..................................CANDIDATE ADMINISTRATIVE INFORMATION...................................

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* 51. What is the name of the person who recommended you for membership?

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* 52. What Institute or organization was the person recommending from

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* 53. What is the email of the person who recommended you?

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* 54. In what year were you recommended (as yyyy)?

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* 55. Are you or any member of your household (0-64) years of age covered by Medicaid, Child Health Plus, Family Health Plus or Private Medical Insurance? (State Yes or No)

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* 56. If You are NOT covered by insurance, do You want to be contacted with information about public health insurance programs?

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* 57. Are you interested in participating in volunteer community service this summer
(For male applicants 18 and over, registered with Selective Service)

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* 58. Enter your Registration Number if You have One, Or Given one in the Past

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* 59. Enter Registration Date as Day/month/Year - If you have one, or have been given in the past

Date
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------------------------ PART II ------------------------

..................................CONFIDENTIAL FINANCIAL INFORMATION....................................
This Questionnaire is CONFIDENTIAL. It is to be seen only by the applicant, the applicant's parents/guardian(s), the mentor, AS&S staff, and student selection Committee members. Income information will be used only for the purpose of verifying eligibility for participation in the Internship program. Demographic information is only for statistical purposes.
Please note that students should be chosen using the following guidelines:
  • Preference is given to students whose total annual family income does not exceed the Association Of Science And Society and Harlem Children Society guidelines shown below.
  • The family income of a 4 member family maximum is Rs 32,000; however, the Committee will support applications from students whose family income is up to Rs 50,000 where no other family member have gone to school, if evidence is provided that factors which contribute to under-representation in the sciences are present.

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* 60. Your Household's total or gross Annual Income

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* 61. How many members are there in your Household (include yourself)?

This Section should be
FILLED BY THE APPLICANT'S (STUDENT'S) CHIEF/RELIGIOUS/CIVIC LEADER

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* 62. My Name Is:

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* 63. My Role is: (for example The Applicant's Chief,Religious Leader,Civic Leader)

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* 64. My Title is:

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* 65. I believe that the Applicant has difficulty with fee payment for the following reason(s):

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* 66. I ask that Association Of Science And Society do the following:

STUDENT BEHAVIOUR CONTRACT
Please read carefully
  • I WILL BEHAVE APPROPRIATELY AND PRESENT MYSELF AS A PROFESSIONAL WITH FULL RESPECT TOWARDS MY MENTORS, IN MY MENTORING INSTITUION, AND FOLLOW THE INSTRUCTIONS GIVEN VERY CAREFULLY.
  • I will attend each Association Of Science And Society lectures when scheduled. For each lecture I miss, appropriate deductions will be made at the discretion of AS&S.
  • I will report and perform my duties designated by my mentor/ guide in accordance with the rules and regulations of the institution and AS&S. For each absence, appropriate deductions will be made at the discretion of AS&S.
  • I agree that the stipend given to me is a scholarship and is being awarded to the discretion of the Association Of Science And Society (AS&S), the distribution of which is at the discretion of the AS&S depending on the availability of funds.
  • I will present my work at a Association Of Science And Society lecture at least once over the course of the summer internship.
  • If I cannot attend my daily internship activities, I will notify my mentor/supervisor as soon as I am able.
  • If I cannot attend a Association Of Science And Society lecture, I will notify Dr. Sat Bhattacharya or the AS&S Staff and mentor/ supervisor as soon as I am able.
  • I will follow all safety regulations and the instructions of my mentor/supervisor.
  • For late and non-submission of Lectures notes, Final Research Report, PowerPoint Presentation and Posters, appropriate deductions will be made at the discretion of ASS.
  • Association Of Science And Society reserves the right to terminate the student contract and the terms of the agreements thereof and reserves the right to make the funds available to the student as and when they are available to AS&S. AS&S reserves the sole right to cancel any or all stipends to the student at any time.

By entering my Full Name and Date below without an accompanying Legal Parent and Guardian, I hereby certify that I attained the Age of Majority (as defined by the laws of my permanent residence), EXCEPT WHEN the Applicant is a Minor (below Age of Majority), THEN I am the Legal Parent and Guardian of the Applicant, giving my Parental Consent (Applicant enters Full Name and Date regardless). Also, regardless whether I am the Applicant or the Legal Parent and Guardian, by entering my Full Name and Date below, hereby certify that I have read, understood and agree to all of the above and that all information that I have entered for myself or on behalf of the Applicant, including all contact information, is true and accurate to the best of my knowledge.

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* 67. (Student Behaviour) Date of Applicant Certification - as mm/dd/yyyy

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* 68. (Student Behaviour) Applicant's Full Name

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* 69. (Student Behaviour) Date Legal Parent and Guardian Certification - as mm/dd/yyyy

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* 70. (Student Behaviour) Legal Parent and Guardian Full Name

MEDIA RELEASE AGREEMENT

I hereby authorize and give permission to the Association Of Science And Society, hereafter known as the ASS to record my name, likeness, image, voice, and performance on film, video tape, audio recording, web, and any other media or otherwise for use in any programs or parts thereof, and grant to the AS&S any and all rights to the said use without compensation. I agree that the such projects may be edited by AS&S as desired by AS&S and used in whole or in part for any and all broadcasting, audio/visual, and /or exhibition purposes in any manner or media, in perpetuity throughout the world. I understand that I have no rights to or any portion thereof, or any benefits derived therefrom AS&S shall own all rights, title, and interest in and to the projects, including the recordings, to be used and disposed of without limitation as AS&S shall in its sole discretion determine.

By entering my Full Name and Date below without an accompanying Legal Parent and Guardian, I hereby certify that I attained the Age of Majority (as defined by the laws of my permanent residence), EXCEPT WHEN the Applicant is a Minor (below Age of Majority), THEN I am the Legal Parent and Guardian of the Applicant, giving my Parental Consent (Applicant enters Full Name and Date regardless). Also, regardless whether I am the Applicant or the Legal Parent and Guardian, by entering my Full Name and Date below, hereby certify that I have read, understood and agree to all of the above and that all information that I have entered for myself or on behalf of the Applicant, including all contact information, is true and accurate to the best of my knowledge.

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* 71. (Media Release) Date of Applicant Certification - as mm/dd/yyyy

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* 72. (Media Release) Applicant's Full Name

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* 73. (Media Release) Date Legal Parent and Guardian Certification - as mm/dd/yyyy

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* 74. (Media Release) Legal Parent and Guardian Full Name

PARENTAL CONSENT
For Minor Volunteers
Please Read Carefully


If I, the applicant, am of legal age, that is NOT a Minor, then the following "I" or "Me" or "My" refers to me as the son and or daughter referred to below, Otherwise, "We" refers to the one or the other, or both, Legal Parent/s and Guardian/s representing the Applicant referred to as our son or daughter as indicated below.
  1. I/We are familiar with the volunteer duties to be performed by our son/daughter and consent to such activity. I/We have been provided an opportunity to ask questions concerning these activities and any questions that have been asked have been answered fully to our satisfaction.
  2. If I/our son/daughter should require emergency care while acting in the course of My/his/her volunteer assignment with the Association Of Science And Society, university, or medical center, the assigned hospital, its physicians, members of its house staff, employees and appropriate designees, to provide whatever emergency care is, in the judgment of the physician(s), considered necessary or advisable including diagnostic procedures, surgical and medical treatment, and blood transfusions.
  3. It is understood that the above treatment is limited to emergency treatment. It is further understood and agreed that if additional treatment is needed for Me/our son/daughter, it will be necessary for us to arrange for it on a private basis.
  4. With the exception of charges resulting from the initial emergency health services event, it is understood and agreed that I/we shall be liable for all costs and charges incurred at the university center, hospital, or elsewhere, on behalf of Me/our son/daughter, and I/we guarantee payment of those costs and charges.

By entering my Full Name and Date below without an accompanying Legal Parent and Guardian, I hereby certify that I attained the Age of Majority (as defined by the laws of my permanent residence), EXCEPT WHEN the Applicant is a Minor (below Age of Majority), THEN I am the Legal Parent and Guardian of the Applicant, giving my Parental Consent (Applicant enters Full Name and Date regardless). Also, regardless whether I am the Applicant or the Legal Parent and Guardian, by entering my Full Name and Date below, hereby certify that I have read, understood and agree to all of the above and that all information that I have entered for myself or on behalf of the Applicant, including all contact information, is true and accurate to the best of my knowledge.

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* 75. (Volunteer Consent) Date of Applicant Certification - as mm/dd/yyyy

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* 76. (Volunteer Consent) Applicant's Full Name

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* 77. (Volunteer Consent) Date Legal Parent and Guardian Certification - as mm/dd/yyyy

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* 78. (Volunteer Consent) Legal Parent and Guardian Full Name

WAIVER FORM


In consideration of being given the opportunity to participate in (AS&S) The Association Of Science And Society's and its associated programs' Activities such as Lab Work during the entire program participation, I, for myself, my personal representatives, assigns, heirs and next to kin:

  1. Acknowledge, agree and represent that I understand the nature of Activities, both indoors and outdoors, and that I am qualified, in good health, and in proper physical condition to participate in all Activities.
  2. FULLY UNDERSTAND that:
    • ACTIVITIES MAY INVOLVE RISKS AND DANGERS of serious bodily injury, including permanent disability, paralysis and death (*Risks*);
    • These Risks and dangers may be caused by my own actions, or inactions, the actions or inactions of others participating in the Activity, the condition in which the Activity takes place, or the negligence of the Releases named below;
    • There may be other risks and social and economic losses either not known to me or not readily foreseeable at the time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my participation in the Activity.
  3. AGREE and WARRANT that I will examine and inspect each Activity in which I take part as a member of the AS&S and that, if I observe any condition, which I consider to be unacceptably hazardous or dangerous. I will notify the proper authority in charge of the Activity and will refuse to take part in the Activity until the condition has been corrected to my satisfaction.
  4. HEREBY RELEASE, discharge, and covenant not to sue Association Of Science And Society, their administrators, board of directors, Grantors, volunteers and employees, other participating regatta organizers, any sponsors, advertisers, and if applicable, owners and lessons of premises, on which the Activity takes place, (each considered one of the Releases herein) from all liability, claims, demands, losses or damages on my account caused or alleged to be caused in whole or in part by the negligence of the Releases or otherwise, including negligent rescue operation; and I further agree that if, despite this release and waiver of liability, assumption of risk, and indemnity agreement, I, or anyone on my behalf, makes a claim against any of the Releases, and I WILL INDEMNIFY, SAVE AND HOLD HARMLESS each of the Releases from any litigation expenses, attorney fees, loss, liability, damage, or cost which any may incur as a result of such claim.

I have read this agreement, fully understand its terms, understand that I have given up substantial rights by signing it and have signed it freely and without any inducement or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law and agree that if any portion of this agreement is held to be invalid, the balance, notwithstanding, shall continue in full force and effect.

By entering my Full Name and Date below without an accompanying Legal Parent and Guardian, I hereby certify that I attained the Age of Majority (as defined by the laws of my permanent residence), EXCEPT WHEN the Applicant is a Minor (below Age of Majority), THEN I am the Legal Parent and Guardian of the Applicant, giving my Parental Consent (Applicant enters Full Name and Date regardless). Also, regardless whether I am the Applicant or the Legal Parent and Guardian, by entering my Full Name and Date below, hereby certify that I have read, understood and agree to all of the above and that all information that I have entered for myself or on behalf of the Applicant, including all contact information, is true and accurate to the best of my knowledge.

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* 79. (Waiver) Date of Applicant Certification - as mm/dd/yyyy

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* 80. (Waiver) Applicant's Full Name

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* 81. (Waiver) Date Legal Parent and Guardian Certification - as mm/dd/yyyy

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* 82. (Waiver) Legal Parent and Guardian Full Name

Intern Confidential Medical Assessment Form

The Indian Medical Association requires that volunteers provide a medical history and, when required, evidence of a physical examination by a physician. This information must be submitted before you begin the internship sponsored by the Association Of Science And Society in the participating institutions. These records will not be available to any other person or agency without your written consent.

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* 83. Applicant's Full Name

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* 84. Allergies

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* 85. Allergy to Penicillin

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* 86. Allergies to Other Drugs

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* 87. Other Allergies

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* 88. Do you have a pacemaker?

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* 89. Have you had surgery within the last 12 months?

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* 90. Do you have any ongoing health problem or physical condition, which should be taken into consideration when determining what your internship assignment should be?

*If yes, you will need to provide medical proof that you are not carrying infectious T.B.
If no, you must provide the result of a T.B. test performed within the past year. If necessary, you can be tested at the participating medical center/ university hospital.

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* 91. Have you tested positive for tuberculosis in the past? See explanation.*

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* 92. Have you tested positive for:

  Rubella? Measles? Varicella(Chickken Pox)?
Please answer all three

PARENTAL CONSENT FORM I
Please read carefully

The undersigned, Applicant and if the Applicant is a minor (below age 18), the Legal Parent and Guardian give consent to the Association Of Science And Society to request the participating university hospital, training facility, or other center participating in the program to draw blood from the Applicant (son/daughter of the Legal Parent and Guardian) exclusively for the purposes of conducting a laboratory test to determine whether the Applicant is immune to chicken pox, rubella, and measles. In addition, this also serves as consent for the Association Of Science And Society to perform a PPD test for tuberculosis.

By entering my Full Name and Date below without an accompanying Legal Parent and Guardian, I hereby certify that I attained the Age of Majority (as defined by the laws of my permanent residence), EXCEPT WHEN the Applicant is a Minor (below Age of Majority), THEN I am the Legal Parent and Guardian of the Applicant, giving my Parental Consent (Applicant enters Full Name and Date regardless). Also, regardless whether I am the Applicant or the Legal Parent and Guardian, by entering my Full Name and Date below, hereby certify that I have read, understood and agree to all of the above and that all information that I have entered for myself or on behalf of the Applicant, including all contact information, is true and accurate to the best of my knowledge.

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* 93. (Consent Form I) Date of Applicant Certification - as mm/dd/yyyy

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* 94. (Consent Form I) Applicant's Full Name

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* 95. (Consent Form I) Date Legal Parent and Guardian Certification - as mm/dd/yyyy

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* 96. (Consent Form I) Legal Parent and Guardian Full Name

PARENTAL CONSENT FORM II
Please read carefully
Make Choice 1 OR Choice 2

Choice 1:
The undersigned, Applicant and if the applicant is a minor (see below), the Legal Parent and Guardian give consent to the Association Of Science And Society to vaccinate Applicant (son or daughter) by the participating university hospital, training facility, or other center participating in the program, if necessary in the event that Applicant tests as being susceptible to measles, rubella and Varicella.

By entering my Full Name and Date below without an accompanying Legal Parent and Guardian, I hereby certify that I attained the Age of Majority (as defined by the laws of my permanent residence), EXCEPT WHEN the Applicant is a Minor (below Age of Majority), THEN I am the Legal Parent and Guardian of the Applicant, giving my Parental Consent (Applicant enters Full Name and Date regardless). Also, regardless whether I am the Applicant or the Legal Parent and Guardian, by entering my Full Name and Date below, hereby certify that I have read, understood and agree to all of the above and that all information that I have entered for myself or on behalf of the Applicant, including all contact information, is true and accurate to the best of my knowledge.

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* 97. (Consent Form II Choice1) Date of Applicant Certification - as mm/dd/yyyy

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* 98. (Consent Form II Choice1) Applicant's Full Name

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* 99. (Consent Form II Choice1) Date Legal Parent and Guardian Certification - as mm/dd/yyyy

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* 100. (Consent Form II Choice1) Legal Parent and Guardian Full Name

OR

Choice 2:
The undersigned, Applicant and if the applicant is a minor (see below), the Legal Parent and Guardian prefer to have the Applicant (son or daughter) vaccinated (if necessary) by the participating university hospital, training facility, or other center participating in the program.

By entering my Full Name and Date below without an accompanying Legal Parent and Guardian, I hereby certify that I attained the Age of Majority (as defined by the laws of my permanent residence), EXCEPT WHEN the Applicant is a Minor (below Age of Majority), THEN I am the Legal Parent and Guardian of the Applicant, giving my Parental Consent (Applicant enters Full Name and Date regardless). Also, regardless whether I am the Applicant or the Legal Parent and Guardian, by entering my Full Name and Date below, hereby certify that I have read, understood and agree to all of the above and that all information that I have entered for myself or on behalf of the Applicant, including all contact information, is true and accurate to the best of my knowledge.

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* 101. (Consent Form II Choice2) Date of Applicant Certification - as mm/dd/yyyy

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* 102. (Consent Form II Choice2) Applicant's Full Name

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* 103. (Consent Form II Choice2) Date Legal Parent and Guardian Certification - as mm/dd/yyyy

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* 104. (Consent Form II Choice2) Legal Parent and Guardian Full Name

PARENTAL LETTER OF CONSENT


Dear Legal Parent and Guardian(s):

This letter is to request your consent (Legal Parent and Guardian) for the Applicant (your child, whose name is entered below) to participate in the Association Of Science And Society Science and Engineering Mentoring Program. Participation is completely voluntary. The purpose of the project is to offer your child an opportunity to learn advanced skills in scientific research, particularly in the areas of bioinformatics, protein chemistry, and molecular biology; and in the technologies (Information Technology - IT) that are used to investigate these subjects and to communicate scientific findings.
To participate in the program, you must consent to your child’s participation, and your child must also agree (assent) to participate. Participation is voluntary and either you or your child may withdraw from the program at any time.

If you consent, your child will:
  • Be paired with a mentor, who will involve your child in his or her research in the laboratory or field setting;
  • Attend after school seminars and activities at major research institutes allocated by AS&S, where project staff and experts will provide training and lessons in science, technology, and careers;
  • Spend the summer continuing in the research placement and at major research institutes allocated by AS&S;
  • Produce a research paper and other products from the research;
  • Take field trips to see what scientists and IT specialists do;
  • Receive guidance in selecting courses for high school and in making choices about higher education and careers.
If you consent, your child and you will be asked to be part of the evaluation of the project. Project evaluation is a way of determining if the project is effective in providing a high quality experience for your child, and if your child is given the opportunity to gain the skills and knowledge the project is designed to teach. Project evaluation also helps to identify what program activities and strategies are working well, so that other programs can make use of effective approaches. Data could be collected in the form of observations, interviews, and surveys of your child, but will be used solely for the purpose of assessing the effectiveness of the program, NOT your child’s participation or performance. All information collected in the evaluation will be confidential.
If you consent, your child will be asked to:
  • Participate in individual assessments, short questionnaires, quizzes about the content, skills, and careers related to the science and technology. This is only for the purpose of adjusting the program to better meet your child’s needs. There are no grades, and these are not tests. We are interested only in supporting your child to have a positive educational experience.
  • Keep a journal reflecting on the experiences in the program, and plans for the future
  • Keep in touch with the project and provide information about high school, college, and career plans.
You will be asked to:
  • Provide information about your ethnic and language background, income, and education. This information is absolutely confidential.
  • Keep a journal, or participate in interviews about your reactions to the program, and about your child’s progress and plans.
  • Fill out short questionnaires about science & technology, and its impact on your community & society.
Your name and/or the name of your young person will not be attached to any information that is used in a report or other public document. Only project staff and the project evaluator will have access to this information. There is a risk of loss of confidentiality of the information that is collected. However, we will make every effort to protect your confidentiality.
The data the project collects will be used for two purposes:
  • To help your son or daughter to learn, build science and technology skills, and make informed choices about education and careers. If a student is having difficulty or moving faster than the program, this information helps staff to adjust the program. There are no grades and the results are not reported to your child’s school or other authority.
  • To share good effective approaches with other programs.
Evaluation and project reports will examine how the program is doing based on putting together all the information that is gathered in this evaluation process. A report might say, for example, that 80% of students gained skills in using a particular software program. Again, individual participants will not be identifiable.
If this is acceptable to you, please sign the following informed consent. If you have any questions, or would like at any point to end your young person’s participation in the project or evaluation process, please feel free to contact us using the contact information below. If you have any questions about your rights as a research subject you may contact AS&S at 033-4070-3382 Thank you! We look forward to working with your young person and you!

Sincerely,

Dr. Sat Bhattacharya

  
Founder, President & CEO, Cancer Research Scientist,
Association Of Science And Society & Harlem Children Society, Cancer Genetics
President, Founder, President & CEO,
Sigma Xi Scientific Research Society, International Society for Advancement of
Rockefeller University Chapter, New York            Science, Technology, Tolerance and Peace

Parental Informed Consent Form
Please read carefully

The undersigned, Applicant and if the applicant is a mInor (see below), the Legal Parent and Guardian consent to the Applicant (child's) participation in the Association Of Science And Society Science Engineering Technology and Mathematics Program.

We understand that our child will:
  • Be paired with a mentor, who will involve your child in his or her research in the laboratory or field setting;
  • Attend after school seminars and activities at the major research institutes allocated by AS&S and experts will provide training and lessons in science, technology, and careers;
  • Spend the summer continuing in the research placement and at major research institutes allocated by AS&S, and other centers identified by Association Of Science And Society;
  • Produce a research paper and other products from the research;
  • Take field trips to see what scientists and IT specialists do;
  • Receive guidance in selecting courses for high school and in making choices about higher education and careers.
We further agree to participate and have our child participate in the evaluation of the project. We understand and consent to our child’s participation in:
  • Individual assessments—short questionnaires, quizzes about the content, skills, and careers related to the science and technology. This is only for the purpose of adjusting the program to better meet your child’s needs. There are no grades, and these are not tests. We are interested only in supporting your child to have a positive educational experience.
  • Writing a journal reflecting on the experiences in the program, and plans for the future.
  • Keeping in touch with the project and providing information about high school, college, and career plans.
We understand that the evaluation asks us to:
  • Provide information about ethnic and language background, income, and education, and that this information will be kept confidential.
  • Keep a journal, or participate in interviews about our reactions to the program, and about our child’s progress and plans;
  • Fill out short questionnaires about science and technology, and its impact on our community and society.
I/We have been told that neither my/our names nor my/our child’s name will be attached to this information in any report or public document. I/We agree that this information may be combined with information from other students and used, in non-identifiable form, for project reports. I/We understand that my/our child must assent to participation on the Student Informed Assent form. I/we have been told that there is a risk of loss of confidentiality of the information that will be collected and that we may withdraw our permission for our child’s participation at any time. If I/we have any questions regarding the project, I/we know that I/we can contact Dr. Sat Bhattacharya, President of the Association Of Science And Society and Principal Investigator of the Science and Engineering Mentoring Project at Association Of Science And Society BJ-284,Sector-II Salt Lake City Kolkata,West Bengal India-700091
By entering my Full Name and Date below without an accompanying Legal Parent and Guardian, I hereby certify that I attained the Age of Majority (as defined by the laws of my permanent residence), EXCEPT WHEN the Applicant is a Minor (below Age of Majority), THEN I am the Legal Parent and Guardian of the Applicant, giving my Parental Consent (Applicant enters Full Name and Date regardless). Also, regardless whether I am the Applicant or the Legal Parent and Guardian, by entering my Full Name and Date below, hereby certify that I have read, understood and agree to all of the above and that all information that I have entered for myself or on behalf of the Applicant, including all contact information, is true and accurate to the best of my knowledge.

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* 105. Please choose the appropriate (Tick)

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* 106. (Parent Informed Consent) Date of Applicant Certification - as mm/dd/yyyy

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* 107. (Parent Informed Consent) Applicant's Full Name

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* 108. (Parent Informed Consent) Date Legal Parent and Guardian Certification - as mm/dd/yyyy

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* 109. (Parent Informed Consent) Legal Parent and Guardian Full Name

Prospective Student Informed Consent Letter
Please read carefully

Dear Prospective Student:

This letter is to request your assent to participate in the Association Of Science And Society Science Technology Engineering and mathematics(STEM) Program. Participation is completely voluntary. The purpose of the project is to offer you an opportunity to learn advanced skills in scientific research, particularly in the areas Science, Technology, Engineering and Mathematics that are used to investigate these subjects and to communicate scientific findings.

In order to participate in the program, your parents must sign the parental consent form, and you must sign the student assent form. Participation is voluntary and either you or your parent(s) may withdraw from the program at any time.

If you assent and your parents/guardians consent, you will:
  • Be paired with a mentor, who will involve you in his or her research in the laboratory or field setting;
  • Attend after school seminars and activities at najor research institutes allocated by AS&S, where project staff and experts will provide training and lessons in science, technology, and careers;
  • Spend the summer continuing in the research placement and at Major research institutes allocated by AS&S, and other institutions recognized by Association Of Science And Society;
  • Produce a research paper and other products from the research;
  • Take field trips to see what scientists and IT specialists do;
  • Receive guidance in selecting courses for high school and in making choices about higher education and careers.
If you assent, you will be asked to be part of the evaluation of the project. Project evaluation is a way of determining if the project is effective in providing a high quality experience for you, and if you are given the opportunity to gain the skills and knowledge the project is designed to teach. Project evaluation also helps to identify what program activities and strategies are working well, so that other programs can make use of effective approaches. Data could be collected from you in the form of observations, interviews, and surveys, but will be used solely for the purpose of assessing the effectiveness of the program, NOT your participation or performance. All information collected in the evaluation will be confidential. However, there is always a risk that there may be some loss of confidentiality of your information. We will make every effort to protection your confidentiality.

If you assent, you will be asked to:
  • Participate in individual assessments—short questionnaires, quizzes about the content, skills, and careers related to the science and technology. This is only for the purpose of adjusting the program to better meeting your needs. There are no grades, and these are not tests. We are interested only in supporting you to have a positive educational experience.
  • Keep a journal reflecting on the experiences in the program, and plans for the future.
  • Keep in touch with the project and provide information about high school, college, and career plans.
You or your family will be asked to:
  • Provide information about your ethnic and language background, income, and education. This information is absolutely confidential.
  • Keep a journal, or participate in interviews about your reactions to the program
  • Fill out short questionnaires about science and technology, and its impact on your community and society.
Your name and/or your parents/guardians names will not be attached to any information that is used in a report or other public document. Only project staff and the project evaluator will have access to this information.

The data the project collects will be used for two purposes:
  • To help you to learn, build science and technology skills, and make informed choices about education and careers. If you are having difficulty or are moving faster than the program, this information helps staff to adjust the program. There are no grades and the results are not reported to your school or other authority. This is simply for the purpose of helping you learn and advance.
  • To share good effective approaches with other programs.
    • Evaluation and project reports will examine how the program is doing based on putting together all the information that is gathered in this evaluation process. A report might say, for example, that 80% of students gained skills in using a particular software program. Again, individual participants will not be identifiable.

    If this is acceptable to you, please sign the following informed assent. If you have any questions, or would like at any point to end your participation in the project or evaluation process, please feel free to contact us using the contact information below.

    Thank you! We look forward to working with you and your family!

    Sincerely,

    Dr. Sat Bhattacharya
    Founder, President & CEO, Cancer Research Scientist,
    Association Of Science And Society & Harlem Children Society, Cancer Genetics
    President, Founder, President & CEO,
    Sigma Xi Scientific Research Society, International Society for Advancement of
    Rockefeller University Chapter, New York      Science, Technology, Tolerance and Peace

Student Informed Assent Form
Please read carefully

I understand that I will:
  • Be paired with a mentor, who will involve your child in his or her research in the laboratory or field setting;
  • Spend the summer continuing in the research placement and at major Science and Technological R&D Institutions recognized by Association Of Science And Society;
  • Produce a research paper and other products from the research;
  • Take field trips to see what scientists and IT specialists do;
  • Receive guidance in selecting courses for high school and in making choices about higher education and careers.
I further agree to participate in the evaluation of the project including:
  • Individual assessments—short questionnaires, quizzes about the content, skills, and careers related to the science and technology.
  • Writing a journal reflecting on the experiences in the program, and plans for the future.
  • Keeping in touch with the project and providing information about high school, college, and career plans.
I understand that the evaluation asks my family to:
  • Provide information about ethnic and language background, income, and education, and that this information will be kept confidential.
  • Keep a journal, or participate in interviews about our reactions to the program.
  • Fill out short questionnaires about science and technology, and its impact on our community and society.
I understand that neither my name nor my parents/guardians’ names will be attached to this information in any report or public document.

I agree that this information may be combined with information from other students and used, in non-identifiable form, for project reports.

My signature below means that I willingly agree to participate.

I understand that my parents/guardian must consent to my participation by signing the parental consent form.

I/we have been told that there is a risk of loss of confidentiality of the information that will be collected and that we may withdraw our permission for our child’s participation at any time.

If I have any questions regarding the project, I/we know that I/we can contact Sat Dr. Bhattacharya, President of the Association Of Science And Society and Principal Investigator of the Science and Engineering Mentoring Project, at the Association of Science and Society BL-243, Sector-II Salt Lake City Kolkata, West Bengal India-700091 bhattacharyas@asciencesociety.org Tel and Fax- 033-4070-3382.
By entering my Full Name and Date below without an accompanying Legal Parent and Guardian, I hereby certify that I attained the Age of Majority (as defined by the laws of my permanent residence), EXCEPT WHEN the Applicant is a Minor (below Age of Majority), THEN I am the Legal Parent and Guardian of the Applicant, giving my Parental Consent (Applicant enters Full Name and Date regardless). Also, regardless whether I am the Applicant or the Legal Parent and Guardian, by entering my Full Name and Date below, hereby certify that I have read, understood and agree to all of the above and that all information that I have entered for myself or on behalf of the Applicant, including all contact information, is true and accurate to the best of my knowledge.

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* 110. Please Choose

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* 111. I am the Applicant and my name is:

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* 112. (Student Informed Consent) Date of Applicant Certification - as mm/dd/yyyy

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* 113. (Student Informed Consent) Applicant's Full Name

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* 114. (Student Informed Consent) Date Legal Parent and Guardian Certification - as mm/dd/yyyy

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* 115. (Student Informed Consent) Legal Parent and Guardian Full Name

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* 116. I am the Applicant and my name is:

CERTIFICATION OF ACCURACY
Please read carefully

I, the undersigned, am of legal adult age and certify that all information on this form is true and correct to the best of my knowledge and understanding. I understand that my statements are subject to verification. I further understand that any false statements may subject me to criminal prosecution under Indian Penal Code.

I agree and accept that I will abide by all applicable rules and regulations of this program.

If you agree to all of the above, type your full name, state that you are the applicant, or the legal adult on behalf of the applicant, who completed this form, as follows:

If you are the Applicant who has reached the age of Majority (as defined by the laws of your permanent residence), then type the following:
I, (your name), am the applicant of legal adult age who has completed this form and have read, understood and agree to all the above.

If you are the Legal Parent and Guardian of the Applicant who is a Minor (below the age of Majority) then type the following:
I, (your name), am the adult of legal adult age, who has completed this form on behalf of the applicant and have read, understood and agree to all the above.

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* 117. Enter your response as indicated

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* 118. Date Application Completed

Date
MMX by Association of Science and Society (AS&S) and Harlem Children Society (HCS).

All rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission of Association of Science and Society (AS&S) and Harlem Children Society (HCS). To find out more about related activities and events please visit our website www.AScienceSociety.org.

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