University of Mary Washington Science Outreach Program
PERSONAL DATA
Name______
Last/Family First Middle
Birth Date (month/day/year) ______E-mail Address______
Mailing Address ______
Number and Street
______
City State Zip Code
Are you a U.S. citizen? q Yes q No
Have you ever been convicted of a crime (other than a traffic violation?) qyes qno
If yes, please state the details on a separate sheet of paper.
Rank the research areas you would be interested in working in this summer (1= 1st choice, 2= 2nd choice, etc; 0 = not interested)
____Biology
____Chemistry
____Computer Science
____Environmental Science
____Geology
____Mathematics
____Physics
Check if you are a member of:
_____ James Farmer Scholars
_____ Rappahannock Scholars
The following items are optional:
wSex: q Female q Male
wPlace of birth: ______
City/County State Country
wIf you wish to be identified with a particular race or ethnic group, please select a race or ethnicity that best describes you (check all that apply):
q African American or Black q Native American or Alaska Native
q Asian (including Indian Subcontinent/ Philippines q Middle Eastern
q Hispanic or Latino q White, non-Hispanic
q Native Hawaiian or Pacific Islander
EDUCATIONAL DATA
High school ______Current GPA _____Date of graduation______
month / year
List any colleges /universities from which you have taken courses for credit.
______
Name of College Location Dates Attended
High school guidance counselor:
Name______
Phone number______Email address ______
Current (or most recent) high school science or math teacher:
Name______Subject ______
Phone number______Email address ______
Have you ever been dismissed from any school? qyes qno
If yes, please state the circumstances on a separate sheet of paper.
FAMILY INFORMATION
Parent 1 ______
Last Name First Middle
Living? qYes qNo (date deceased) ______
Home address if different from yours ______
Number and Street
______
City State Zip Code
Occupation ______Name of business or organization______
Education (indicate last grade completed, or any colleges attended and degrees earned)
______
HS College Degree
Parent 2 ______
Last Name First Middle
Living? qYes qNo (date deceased) ______
Home address if different from yours ______
Number and Street
______
City State Zip Code
Occupation ______Name of business or organization______
Education (indicate last grade completed, or any colleges attended and degrees earned)
______HS College Degree
ADDITIONAL APPLICATION MATERIALS:
Written statement: Write and attach a one-page essay indicating which STEM field(s) you are most interested in, describing your future goals, and explaining how this internship might be beneficial towards those goals.
Letter of recommendation: Include (or have mailed separately) a SEALED letter of recommendation from a science or math teacher.
Current transcripts: Include a copy with your most recent grading period and SOL scores.
I certify that all the information in my application, including my written statement, is my own work, and is factually true and honestly presented.
Signature______Date ______
Parent or Guardian’s Signature______Date ______
Please complete this application, attach the written statement and high school transcripts, and mail it by March 18 to:
Dr. Abbie Tomba
Department of Biological Sciences
University of Mary Washington
1301 College Avenue
Fredericksburg, VA 22401