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Preliminary application seed2013

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  • 1. Preliminary Application for Project SEED Please complete and Return by March 30, 2013Project SEED is a program sponsored by the American Chemical Society (ACS) that provides high school studentswith summer research experiences in chemical laboratories. The program is focused on students who areeconomically disadvantaged. Students are selected based on family income, number of members in the family,history of college attendance in the family, and interest and performance in science courses.Please provide the following information. This will be kept confidential and will be used exclusively in theselection process. If chosen on the basis of this form, you will be interviewed for participation.Student Information (All fields MUST be completed)Name __________________________________________________________________Address ________________________________________________________________City ___________________ State _____ Zip ___________Phone: ___________________________ e-mail ______________________________Birth Date ________________________Grade entering in Fall 2013:  10th  11th  12thList Chemistry Course(s) taken: _____________________________________________GPA in Chemistry Courses __________Parent/Guardian InformationName __________________________________________________________________Address ________________________________________________________________City ___________________ State _____ Zip ___________Phone: ___________________________Total Family Income (year 2012) $______________ Family size including you ________Proof of income (2012 tax return) will be required if you are invited to participate.Student’s High School InformationHigh School _____________________________________________________________Chemistry Teacher ___________________________Recommending Teacher’s Contact Information:_____________________________________________________________________________________________________________________________________In the space below and/or on the reverse, briefly describe why you would like to participate in Project SEED.Return to pbays@saintmarys.edu, or J. Philip Bays, Department of Chemistry & Physics, Saint Mary’s College, Notre Dame, IN 46556

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