Summer Youth Scholars Program
Hispanic Center of Excellence Summer Youth Scholars program Summer 2018
First Name *
Last Name *
Gender *
Email *
Full Address *
Date of Birth *
Phone number *
Race *
Ethnicity *
School Name *
Current Grade *
Country of Birth *
Parent 1 Name *
Parent/Guardian Marital Status *
Parent 1 Address *
Parent 1 Email *
Parent 1 Phone Number *
Parent 1 Highest Level of Education *
Parent 2 Name
Parent 2 Address
Parent/Guardian Marital Status
Parent 2 Email
Parent 2 Phone Number
Parent 2 Highest Level of Education
School Counselor's Name *
School Counselor's Phone Number *
What Science Courses have you taken? *
Have you taken the PSAT or SAT? *
If yes, what was your total score? (enter 0 if you did not take) *
What was your score for Math? (enter 0 if you did not take) *
What was your score for Reading?(enter 0 if you did not take) *
What was your score for Writing?(enter 0 if you did not take) *
Have you participated in prior NJMS programs? If so please list *
Are you interested in a Health Science Career *
Emergency Contact Name *
Emergency Contact Phone Number *
Do you (the applicant) have any medical conditions? If so please list: *
Do you (the applicant) have any food allergies? If so, please advise: *
Email Program essay to
In 2 pages, include information on personal attributes, future goals, reason for applying to this program, and what you plan to accomplish by participating. Personal statements must be written in English. Following a Pre-Screening, Selected Students will be interviewed before final acceptance into the program
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