VERNA J. KIRKNESS
SCIENCE AND ENGINEERING EDUCATION PROGRAM
APPLICATION
The Kirkness Program provides the opportunity for Grade 11 First Nations, Métis or Inuit students to spend one week in a science or engineering research laboratory.
Applications must be received by February 17, 2017.
CHECK TO ENSURE YOUR APPLICATION INCLUDES:
☐COMPLETED (TYPED) APPLICATION, INCLUDING SIGNED CONSENT FROM PARENT OR GUARDIAN
☐Please check here (if you do not have a scanner) to indicate that you will be faxing your Parental Consent separate from the emailed application.
☐Please check here if you plan to fax the entire application (instead of email).
☐ LETTER OF REFERENCE FROM YOUR TEACHER OR GUIDANCE COUNSELLOR
COMPLETE THE FOLLOWING WITH YOUR TEACHER OR GUIDANCE COUNSELLOR.
☐Fill in the required fields on a computer for pages 1-3.
☐ Print page 4. Complete, sign and scan or fax per above.
☐ Refer to 'APPLICATION GUIDELINES' (pages 5-7) for detailed instruction to help you complete your entire application.
PART 1 - STUDENT INFORMATION
Last name: First name:
Gender: ☐M ☐F Preferred language: ☐Fr ☐En
I am: ☐First Nations ☐Métis ☐Inuit Date of birth: (D/M/Y)
Required by airlines and university
Email address:
Phone number:
Street Address:
City: Province: Postal Code:
PART 2 - PARENT/GUARDIAN/TEACHER INFORMATION
Parent or guardian:
Parent or guardian email address:
Parent or guardian phone number:
Teacher or counsellor submitting application:
Teacher or counsellor email address:
School:
School mailing address (intended for program acceptance correspondence c/o teacher/guidance counsellor)
Street:
City: Province: Postal Code:
PART 3 - RESEARCH PROGRAMS
Go to the website and look at the program offered at the university closest to your home. Refer to http://www.vernajkirkness.org/application-form/research-areas/ for a list of research projects and faculty. Indicate your top three choices (in order of preference) by listing a program below.
Project name: / Faculty name: / University of:1
2
3
If you are accepted, we will try and match each student’s research preference but this is not always possible. Applicants must be prepared to work in any laboratory that is assigned to them.
PART 4 - REFERENCE
☐(Please check) - ASK YOUR TEACHER OR GUIDANCE COUNSELLOR TO WRITE A LETTER OF REFERENCE AND LIST HIS/HER NAME BELOW.
Consider the person who you wish to write your Reference Letter for you. Approach them in person or by email and ask:
“Are you willing to write a Reference Letter for me as part of the application process for the Verna J. Kirkness Science and Engineering Education Program? I would like to apply to spend one week to experience what it would be like to be a university student. A Reference Letter is required for the application. Would you like to help me out?”
Make sure to remind the teacher or guidance counsellor who is submitting your application to include the Reference Letter when submitting the application.
Name of Reference:
Email:
Phone:
PART 5 - ESSAY
In a maximum of 300 (TYPED) words, please explain why you are interested in attending the Verna J. Kirkness Science and Engineering Education Program. This essay is the most important part of the application. The more information you provide, the better chance you have of being accepted. Applications with less than 50 words will not be accepted.
Click here to enter text.☐(Please check) - FOLLOWING THE COMPLETION OF THE PROGRAM, I AGREE TO PROVIDE THE VERNA J. KIRKNESS SCIENCE AND ENGINEERING EDUCATION PROGRAM WITH SHORT WRITTEN UPDATES ON AN ANNUAL BASIS ABOUT MY ONGOING EDUCATIONAL ACTIVITIES.
PART 6 - PARENTAL CONSENT
Print this page and ask your parent or guardian to complete it. Give the signed consent to your teacher or guidance counsellor. Completed Parental Consent Form can be scanned and emailed to or, if you do not have a scanner, please fax to 204-258-2063.
I (Name of parent/guardian) understand that (Name of applicant) (hereinafter called the “applicant”) has applied to participate in the Verna J. Kirkness Science Education Program (hereinafter called the “Program”) at the University of Manitoba, University of Saskatchewan or University of British Columbia (to be determined at a later date).
I understand that participation in the Program will involve:
1) The applicant spending one week living on campus and working as part of a research team at a University.
2) As part of the participation in the Program, the applicant working with a research team in a laboratory setting, for which they will be provided with basic safety training as arranged by the Program.
3) During their involvement in the laboratory, the applicant being mentored and supervised primarily by a graduate student.
4) During periods of time outside of daily learning activities, the applicant spending time supervised by the Program chaperones. This may include afternoon and evening activities, with the applicant sharing a room with another participant of the same gender.
I understand that there are certain expectations regarding the applicant’s conduct during their involvement in the Program, which will be explained to the applicant. These expectations include:
· The applicant following the instructions given to them by the mentor or lab supervisor.
· The applicant following all safety protocols in place during the program.
· The applicant conducting him/herself in a respectful and mature manner at all times.
· The strict prohibition of the consumptions or possession of alcohol or illegal substances.
· Violation of any of the above rules may result in the applicant being asked to leave the Program.
I understand that participation in the Program may involve the applicant coming into close proximity with, and working with scientific apparatuses and/or materials that may be dangerous if mishandled. I understand that all participants will be asked to complete a survey at the end of the Program.
I further understand that, if the applicant is accepted to participate in the program, I will be required to sign a situation specific consent form prior to his/her participation fully indemnifying the host University, as well as the program planners, administrators and personnel from any and all liability for any injury which may be suffered by the applicant during his or her participation.
Having read the above, I consent to the applicant’s submission of an application to participate in the Verna J. Kirkness Science and Engineering Education Program.
Signature Relationship to applicant Date (day-month-year)
PRINT NAME:
PHONE NUMBER:
EMAIL ADDRESS:
APPLICATION GUIDELINES
Applications must be received by February 17, 2017.
STEP 1: CHOOSE YOUR PROGRAM
1. Review the list of current faculty and research projects at http://www.vernajkirkness.org/application-form/research-areas/ and decide if there is a project or laboratory that interests you.
In most cases, students will be matched to the campus nearest your home. Every effort, where possible, and based on Program criteria, will be made to match you to your project of choice, if available. If your preference is not offered at the university closest to you, consideration will be given to offer out-of-province projects to select individuals based on the merit of your application.
STEP 2: COMPLETE STUDENT, PARENT/GUARDIAN/TEACHER AND RESEARCH PROGRAM INFORMATION (Parts 1, 2 and 3 of the Application)
1. Read Application Guidelines and download application at http://www.vernajkirkness.org/application-form/
2. Let a parent or guardian know that you would like to apply to the Verna J. Kirkness Program, and that he/she/they will be required to complete a Consent Form, as part of the application. Print Page 4 - Parental Consent of the Application and give this to your parent or guardian.
3. Ask your teacher or guidance counsellor to help you with the application. All applications must be submitted by a teacher or guidance counsellor on the student’s behalf.
4. Complete Parts 1 and 2 of the Application - these must be typed.
☐Complete Part 1 - Student Information
☐Complete Part 2 - Parent/Guardian/Teacher Information
☐Complete Part 3 - Research Program Information
☐In the table, indicate your Top 3 project choices by listing, in order of preference, the
☐NAME of project (as listed at http://www.vernajkirkness.org/application-form/research-areas/)
☐Faculty first name and last name
☐University - If you select a project that is being conducted at university that is not located in your province, provide your reason for choosing that project in the section of the application: PART 5 - ESSAY.
5. Save your Application (Parts 1, 2, 3 / Pages 1-2) to a computer.
STEP 3: ASK FOR A REFERENCE LETTER (Part 4 of the application)
1. Ask your teacher or guidance counsellor to ensure that your application will include a letter of reference. Your teacher or guidance counsellor can be your reference, or you may choose someone different to be your reference. Your reference letter must be submitted at the same time as the application.
2. Consider the person who you wish to write your Reference Letter for you. Approach them in person or by email and ask: Are you willing to write a Reference Letter for me as part of the application process for the Verna J. Kirkness Science and Engineering Education Program? I would like to experience what it would be like to be a university student. A Reference Letter is required for the application. Would you like to help me out?
3. If your contact agrees to be your reference, complete the area on the application marked Part 4 - Reference. Be sure to include the First name and Last name, Email address, and Phone number of the person who will be writing your Reference Letter.
4. Save your updated Application (including Part 4 / Page 2) to a computer.
5. If the Reference is not your teacher or guidance counsellor, make sure to remind your Reference to send his or her letter directly to the teacher or guidance counsellor submitting your application. If the teacher or guidance counsellor submitting your application is also writing your reference letter, remind them to include the Reference Letter in the application.
6. All References will be contacted as part of the application review process.
STEP 4: WRITE YOUR ESSAY (Part 5 of the application)
1. On Part 5 (Page 3 of the application), there is a box in which you can explain why you are interested in attending the Verna J. Kirkness Science and Engineering Education Program. This is the fun part! It is an opportunity for you to be creative, to bring forth your ideas, to share something about yourself that explains why this program is of interest to you. Don’t be shy! Everyone is unique; everyone has a unique story. Tell us something about yourself relevant to your personality and goals as they relate to education, science, engineering, and/or your life.
2. This essay is the most important part of the application. The more information you provide, the better chance you have of being accepted. Applications with less than 50 words will not be accepted.
3. Your essay must be typed.
4. Successful applicants who complete the program will be asked to provide the Verna J. Kirkness Science and Engineering Education Program with a brief written update (on an annual basis) about your ongoing educational activities following the program. Please check the box to indicate that you are willing to do this. These updates play an important role in measuring the success of the Verna J. Kirkness Science and Engineering Education Program.
5. Save your updated Application (including Part 5 / Page 3) to a computer.
6. Go to Step 5. Once you get a completed Parental Consent, you can email or fax the Completed Application along with your Parental Consent + Reference Letter.
STEP 5: ASK YOUR PARENT OR GUARDIAN TO SIGN THE PARENTAL CONSENT (Part 6 of the application)
1. Print Page 4 of the application. Ask your parent or guardian to complete the following:
☐Signature / Relationship to student/ Date
☐Printed Name
☐Email address
☐Phone number
2. If your parent or teacher has the ability to scan the consent letter, then scan and email the completed Parental Consent along with your completed application. If this is not possible, you can fax the Parental Consent separately to 204-258-2063.
☐If you plan to fax the Parental Consent, please let us know by checking the box at the top of Page 1 so that we can expect your fax before the deadline.
3. In order for you to be accepted into the program, a Verna J. Kirkness representative will speak to your parent or guardian to arrange travel plans and ensure that they support your participation in the Program.
If you have any questions about the application process, please email . Completed applications must be received by February 17, 2017.
All applicants (as well as your teacher or guidance counsellor and parent(s) or guardian) will be notified of the results of the application via email by the end of February, 2017.
Successful applicants will be required to complete additional consent forms specific to the University they will be attending, such as a Parent Consent Form for the university, and provide additional information including allergies, medications, and a list of electronic devices they will be bringing with them. Please provide accurate contact information. If we are unable to speak directly to your Parent or Guardian you will not be accepted into the Program.
Thank you for applying to the
Verna J. Kirkness Science and Engineering Education Program
Increasing the number of First Nations, Métis and Inuit students
graduating from science and engineering programs in Canada
VJK Application - Page 2 of 7 http://www.vernajkirkness.org