Summer Youth Scholars Program
Hispanic Center of Excellence Summer Youth Scholars program Summer 2017
First Name
Last Name
Full Address
Date of Birth
Phone number
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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