2018 AWSM GIRL SCOUTS of NASSAU COUNTY

SUMMERINTERNSHIP-SCHOLARSHIP APPLICATION

Due by January 16th, 2018

Please Type/Print

DATE: ______APPLICANT MUST BE AT LEAST 15 YEARS OLD BY JUNE 1st, 2018.

Information

Last Name ______First Name ______

Home Address: ______

StreetCity/StateZip Code

Home Phone: ______E-Mail:______

Cell Phone: ______Date of Birth: ______/______/______Grade: 10th11th

I attended theOctober 18th, 2017 AWSM-GSNC event held at the Feinstein Institute Yes No

Emergency Contact:

______

Name Phone # (home and cell)Relationship

The following is optional, but the information helpful:

Race: African-American American Indian Asian Indian

Pacific Islander White – Hispanic Origin White – Non-Hispanic Origin Other

Current Status

Current Student at: ______

School Address:______Street Address Town/City

I plan to participate in:

LISEF yesno don’t knowRegeneron STS yesno don’t know

Siemens Compyesno don’t knowOther programsyesno don’t know List:

Applicants should be available for 30 to 35 hours per week for participation in this 6 to 8 week long research internship.

Approximately, the first day you can work (Month/Day): ______

Approximately, the last day you can work (Month/Day): ______

References

Please provide two references (at least one science teacher; no family members). References should submit letters of recommendation to Patricia Donohue-Brownby January16th, 2018 (contact information listed on page 4).

Reference 1:

______

Name Relationship

Reference 2:

______

Name Relationship

You can visit the Feinstein Institute of Medical Research Website and read about the variety of research topicsthat are being investigated. Please list your top two research topics of interest below.

Topic #1: ______Topic #2: ______

Why? Please limit your response to 250 words or less.

What do you hope to accomplish during this internship? Please be as specific as possible with your expectations of what sorts of experience you want to have. Please limit your response to the space below. Note: This is an unpaid internship opportunity. However, a scholarship will be awarded for educational endeavors.

Federal, state and local law prohibit discrimination because of age, race, creed, color, religion, sex, national origin, citizenship status, disability or sexual preference.

I certify that all matters contained in this application are true, authorize their investigation and agree that any misleading or false statements would render this application void and would be sufficient cause for immediate dismissal from the program. I understand that acceptance into the program is subject to a satisfactory completion of a medical examination and receipt by the Institute of satisfactory references. I am aware that I am applying for a laboratory assignment, with no present or future promise of compensation for my services.

I acknowledge that I will treat as confidential all information that I may read or hear, directly or indirectly. If accepted for the program, I agree to conform to the rules and regulations of the Institute. I understand that I will be required to attend an Orientation Program and participate in any training specific to my assignment. I acknowledge that the Institute may discontinue my status at any time and for any reason.

Signature of applicant: ______Date: ______

Please email this signed and completed application along with two letters of recommendations and up-to-date school transcripts to:

Patricia Donohue-Brown
STEM Program Specialist
Girl Scouts of Nassau County

In subject box: AWSM SUMMER INTERNSHIP-SCHOLARSHIP

For questions regarding the application, please contact

Anne Davidson, MBBS ()

Christine Metz, PhD ()

Parental Permission for Minors (under 18 years)

I understand that my daughter may be working with hazardous chemicals, radioactive materials and biological materials. The High School Intern Research Program for Scientific Competitions will provide training in the safe handling of these items. I give my daughter permission to participate in the AWSM Girl Scouts of Nassau County Summer Internship-Scholarship Program at The Feinstein Institute for Medical Research at Northwell Health.

Parent’s Signature: ______Date: ______

All students under the age of 18 must obtain working papers, which may be issued through their High School.

Revised 08/25/17