StatePre-CollegeEnrichmentProgram(S-PREP)
Program Application
The State Pre-College Enrichment Program is an academic enrichment program designed for students who are
seriously interested in pursuing a career in medicine or related STEM professions. Applicants must be New York
residents who identify as underrepresented minority (e.g., Black, Hispanic, Native American, or Alaskan Native)
or economically disadvantaged (see economic eligibility guidelines) students enrolled in grades 7 – 12. The
long range objective of the program is to increase the number of underrepresented minority in healthcare and
STEM professions.
S-PREP offers enrichment courses and activities geared towards preparing students for success in math and
science.
In addition to the rigorous academic schedule, the program offers college preparation and career
development workshops, college counseling services, field trips and college tours. S-PREP demands that students
attend consistently and give their best effort. Unexcused absences will not be permitted in the summer
program. Failure to comply with such expectation may result in immediate dismissal from the program.
Therefore, students who are heavily involved in other extracurricular activities or pre- college exam
preparation courses should seriously consider whether or not they can commit to the program.
In
addition, students are expected to maintain an 80% grade average in math and science. Students will be
required to submit a copy of their report card to the program on a quarterly basis.
Students enrolled in S-PREP are selected on the basis of character and academic merit that aligns with the
eligibility criteria outlined below:
80% grade average, in math and science
A strong interest in medicine, research or STEM professions
The ability to commit to the course schedule and
A mature personality
All Program Applications and Supplementary documents must be received by the following deadlines:
Academic Year: September 15th Summer Semester: March 15th
Mail your application and all supporting materials to:
Columbia University, College of Physicians and Surgeons
Office of Diversity and Multicultural Affairs
104 Haven Ave, Suite 1003
Attention: S-PREP
New York, NY 10032
For more information, contact (212) 305-4157 or sprep-ps@cumc.columbia.edu
The State Pre-College Enrichment Program is offered by the Office of Diversity and Multicultural Affairs at
Columbia University, College of Physicians and Surgeons and the New York State Education Department.
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StatePre-CollegeEnrichmentProgram(S-PREP)
Program Application
All information provided in this application is confidential. Please type or print legibly.
Fill out all sections completely. If not applicable, please put N/A. Applications with missing
information or signatures will not be reviewed.
PART I: APPLICATION
Today’s date: Current Grade: Grade you will be entering in the fall:
Print Name:
First Middle Last
Home Address:
House No./Street Name/ Apt. No
City/State/Zip Code
Email Address:
Home Phone #: Cell Phone:
Date of Birth: Place of Birth:
Gender: □ Male □ Female NY State Resident: □Yes □ No
US Citizen: □Yes □ No Permanent Resident (if applicable): □Yes □ No
Ethnicity1
: (Check one)
□ African American/Black* □ Hispanic/ Latino (specify):
□ American Indian/ Alaska Native □ Other (specify)**:
* Includesstudentsfrom Africa and the Caribbean.
** If you checked “other”, please refer to Appendix Guidelines for Student Eligibility to determine if you
are economically disadvantaged. If you do not provide financial documentation as required byNew York State,
your application will not be accepted.
1 For the purpose of STEP, minorities historically underrepresented in the scientific, technical, health related and
licensed professionals include residents of New York who are Black or African American, American Indian, Alaska
Native, or Hispanic/Latino.
PERSONAL INFORMATION
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StatePre-CollegeEnrichmentProgram(S-PREP)
Program Application
School:
Address:
Guidance Counselor: Phone #:
NYSSIS*: Expected Graduation Date:
*New York State Student Identification Number (ie. OSIS #/ Student ID #) If you do not know this number please contact your school.
What Math and Science courses will you be taking this upcoming Fall Semester?
Please provide course name/number and indicate if it is a Non Regent (NR), Regent (R), or Advance Placement (AP) course.
MATH COURSES SCIENCE COURSES
Please list awards received in middle and/or high school:
____________________________________________________________________
____________________________________________________________________
_________________________________________________________________
Please list your extracurricular activities (school, community, church, involvement in other programs)
____________________________________________________________________
____________________________________________________________________
_________________________________________________________________
How did you hear about S-PREP? Check all that apply:
□ Recruitment Fair □Counselor □Email □Family/Friend/Colleague: __________
□Website □Teacher □Other (specify):
ACADEMIC DATA
Standardized Test Scores: Write NYT for any tests “Not Yet Taken”
PSAT Reading: ________________ PSAT Math: ___________________ Date Taken: _____________
SAT Reading: _________________ SAT Math: _____________________ Date Taken: _____________
SAT II (Subject): _________________ SAT II Score: ___________________ Date Taken: _____________
ACT Math: ______ ACT Reading: ______ ACT English: _____ ACT Science:_____ Date Taken: _____________
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StatePre-CollegeEnrichmentProgram(S-PREP)
Program Application
Please note that if you checked “other” for ethnicity you must fill out the portion below and provide
verification as outlined in the appendix (pg. 9).
Annual Income: $ Total # of People in Household:
Source of Income:
□ Employment □ Unemployment □Social Service □Social Security □Other:
Student Resides with: □ Mother & Father □Mother □Father □Other:
GUARDIAN I: □ Mother □Father □Other:
Guardian Name: Phone #:
Home Address:
Email: Work #:
GUARDIAN II: □ Mother □Father □Other:
Guardian Name: Phone #:
Home Address:
Email: Work #:
PART II: ESSAY
PART III: OFFICIAL TRANSCRIPT & REPORT CARD
Please include a copy of BOTH your official transcript and most recent report which includes your most
recent class grades.
PART IV: LETTERS OF RECCOMENDATION
Two (2) letters of recommendation must be submitted with the application. The letters should be from a
math teacher, science teacher and your counselor. Please provide your recommendations with the forms
included with this application.
HOUSEHOLD INCOME
FAMILY DATA
Prompt: On a separate page, type an essay of max 500 words on “Why I Believe I Would Be a Good Candidate
for the SPREP Program”. Include a discussion about your expectations of the program, what you plan to
contribute to the program and your short and long term career goals. Sign your name at the end of the essay.
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StatePre-CollegeEnrichmentProgram(S-PREP)
Program Application
PART IV: TEACHER/COUNSELOR LETTER OF RECOMMENDATION
S-PREP is a rigorous program designed for minority and economically disadvantaged middle and high school students who are
seriously interested in pursuing a career in medicine or health related profession.
Please fill out this form and make additional comments about the student’s potential. Most helpful are specific examples
evidencing the student’s personal and academic achievements.
Check here if you would like your comments to be kept confidential: □
Student’s Name: ___________________________________________ Poor Fair Good Excellent
Academic Performance ………………………………………………………………
Academic Potential……………………………………………………………………
Character and Maturity………………………………………………………………..
Enthusiasm and Initiative……………………………………………………………..
Work Ethic…………………………………………………………………………….
Why do you believe that this student is a good candidate for S-PREP?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What can this student contribute to the program?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
How do you think this student will benefit from the program?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Summary Evaluation Please use other side for additional comments if needed.
I do not recommend this applicant for admission to your program.
I believe that the applicant is marginally qualified for your program, but has potential.
I recommend this applicant for admission to your program.
I strongly recommend this applicant for admission to your program.
Signature: _____________________________________________ Date: _________________________________
Name: ________________________________________________ School: ________________________________
Title and department: ______________________________________ Telephone: (______) __________________
Mail this form directly to the Program Administrators at the address below:
Columbia University, College of Physicians and Surgeons
Office of Diversity and Multicultural Affairs
Attention: S-PREP
104 Haven Ave Suite 1003 ● New York, NY, 10032
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StatePre-CollegeEnrichmentProgram(S-PREP)
Program Application
PART IV: TEACHER/COUNSELOR LETTER OF RECOMMENDATION
S-PREP is a rigorous program designed for minority and economically disadvantaged middle and high school students who are
seriously interested in pursuing a career in medicine or health related profession.
Please fill out this form and make additional comments about the student’s potential. Most helpful are specific examples
evidencing the student’s personal and academic achievements.
Check here if you would like your comments to be kept confidential: □
Student’s Name: ___________________________________________ Poor Fair Good Excellent
Academic Performance ………………………………………………………………
Academic Potential……………………………………………………………………
Character and Maturity………………………………………………………………..
Enthusiasm and Initiative……………………………………………………………..
Work Ethic…………………………………………………………………………….
Why do you believe that this student is a good candidate for S-PREP?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What can this student contribute to the program?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
How do you think this student will benefit from the program?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Summary Evaluation Please use other side for additional comments if needed.
I do not recommend this applicant for admission to your program.
I believe that the applicant is marginally qualified for your program, but has potential.
I recommend this applicant for admission to your program.
I strongly recommend this applicant for admission to your program.
Signature: _____________________________________________ Date: _________________________________
Name: ________________________________________________ School: ________________________________
Title and department: ______________________________________ Telephone: (______) __________________
Mail this form directly to the Program Administrators at the address below:
Columbia University, College of Physicians and Surgeons
Office of Diversity and Multicultural Affairs
Attention: S-PREP
104 Haven Ave Suite 1003 ● New York, NY, 10032
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StatePre-CollegeEnrichmentProgram(S-PREP)
Program Application
PART V: PARENT/GUARDIAN MEDIA CONSENT FORM
(Publications, Video, Internet, Local Media, and Use of Personal Information)
SPREP students are sometimes asked to be part of our program publicity,
publications and/or public relations activities. To ensure student privacy and
agreement for your child to participate, please sign the consent below for each child
participating in the program. Your signature indicates approval or denial for the
student’s name, picture, written work, voice, verbal statement or portraits (video or
still) to appear in our newspaper, videos or on our department websites.
Parent/ Guardian understand and agree that:
• Consent and release may be changed at any time by parent/guardian completing a new consent form.
• Photos, video orstudentsstatements may be used in subsequent years.
• Thisform will be kept in the student’stemporary record.
• School report cards, transcripts,standardized testing scores may be collected on your behalf.
• Student name and contact information may be shared with other STEP/CSTEP Programs and
college/universityadmissionsoffices.
Note: all information will be kept confidential
YES, I give my consent to the above.
NO, I do not give my consent to the above.
StudentName:
Parent/Guardian Name (PleasePrint):
Parent /Guardian Signature:
Date:
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StatePre-CollegeEnrichmentProgram(S-PREP)
Program Application
APPLICATION CHECKLIST
Only complete applications will be reviewed. To ensure that your application is complete, please make sure
you have included the following materials:
□ PART I: Complete Application Form (Pgs. 1 - 3)
□ PART II: Essay
□ PART III: Official Transcript and Report Card
□ PART IV: Two (2) Letters of recommendation from a science teacher, a math teacher or a Guidance
Counselor
□ PART V: Parent’s/Guardian Consent Form- Publication, Video, Internet, Local Media, and Use of
Personal Information
□ Financial Documentation- Only for applicants who do not meet the race/ethnicity criteria, see Financial
Guidelines attached (pgs. 8-9)
□ Awards, Certificates, Honors Received (Optional)
Please make sure to keep a copy of your application in case it gets lost in transit.
MAIL YOUR COMPLETED APPLICATION PACKET TO:
Columbia University, College of Physicians and Surgeons
Office of Diversity and Multicultural Affairs
Attention: S-PREP
104 Haven Ave, Suite 1003
New York, NY 10032
Applications must be received by:
Academic Year: September 15th Summer Semester: March 15th
Should you have questions or concerns regarding the application process, please contact the
S-PREP Program at (212) 305-4157 or sprep-ps@cumc.columbia.edu.
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StatePre-CollegeEnrichmentProgram(S-PREP)
Program Application
APPENDIX: GUIDELINES FOR STUDENT ELIGIBILITY
The Science and Technology Entry Program is designed for students attending secondary school (grades 7-12)
in New York State who are either minorities historically underrepresented in the scientific, technical, health
related and licensed professions, or economically disadvantaged as defined below. For the purpose of STEP,
minorities historically underrepresented in the scientific, technical, health related and licensed
professions include residents of New York State who are African American, American Indian/ Alaska
Native or Hispanic. If you are economically disadvantaged, you may be eligible for STEP. Please
refer to the guidelines below and provide the required documentation.
For the purpose of STEP, a student is considered a New York State resident if he or she resides in New York
State and has lived in New York State for the last two terms of school prior to entry into the STEP Program, or
has resided in New York State for at least 12 months immediately preceding the first term for which he or
she is seeking participation in the STEP Program.
The economic eligibility standards set forth in this Appendix apply only at the time of application to the
Science and Technology Entry Program. Once admitted, a participant may continue to receive services, even if
the family income rises above the current eligibility standards.
1. Economic Eligibility Criteria for First-Time Students
A student is considered economically disadvantaged if he or she is a member of:
• a household supported by one parent if dependent, by the student or by a spouse if independent,
whose total annual income is not more than the applicable amount listed in the table below; or
• a household supported solely by one member thereof who works for two or more employers with a
total annual income which does not exceed the applicable amount set forth in the following table by more
than $1,800; or
• a household supported by more than one worker (parents if dependent, student and spouse if
independent) in which the total annual income does not exceed the applicable amount listed in the
table below by more than $4,800; or
• a household supported by one worker (parent if dependent, student if independent) who is the sole
support of a one-parent family in which the total annual income does not exceed the applicable amount
listed in the table below by more than $4,800.
• Beginning with the 2012-13 year all add-on allowances were discontinued. Eligibility determination
should be based on figures listed on the income chart below.
The number of members of a household shall be determined by ascertaining the number of individuals
living in the student’s residence who are economically dependent on the income supporting the student.
For students first entering the Program between July 1, 2009 and June 30, 2010:
Income Eligibility Criteria
2013-14 through 2015-16 Number in
Household Dependent on Income 2013-14 2014-15 2015-16 2016-2017
1 $ 21,257 $ 21,590 $ 21,755 $ 21,978
2 $ 28,694 $ 29,101 $ 29,471 $ 29,637
3 $ 36,131 $ 36,612 $ 37,167 $ 37,296
4 $ 43,568 $ 44,123 $ 44,863 $ 44,955
5 $ 51,005 $ 51,634 $ 52,559 $ 52,614
6 $ 58,442 $ 59,145 $ 60,255 $ 60,273
7 $ 65,879 $ 66,656 $ 67,951 $ 67,951
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StatePre-CollegeEnrichmentProgram(S-PREP)
Program Application
Exceptions
Reference to the household income scale need not be made if the student falls into one of the following
categories and documentation is available:
a . The student’s family is the recipient of:
(1) Family Assistance Program Aid, or
(2) Safety Net Assistance through the New York State Office of Temporary and Disability Assistance,
or a county Department of Social Services, or
(3) family day care payments through the New York State Office of Children and Family Services
Assistance, or a county Department of Social Services.
b . The student is a ward of the State or a county.
2. Documentation
Please provide only one of the following documents. The following shall be acceptable documentation of
economic eligibility:
a. Documentation of all income, earned dividends and interest: a signed copy of appropriate year’s
tax returns (IRS Forms 1040, 1040A, 1040EZ, or 4506).
b. Documentation of a sole worker’s income from two or more employers: W2’s for the appropriate
year or similar documentation acceptable to the Commissioner.
c. Documentation of no income: a copy of IRS Form 4506 which has been filed by the student or
family with the Internal Revenue Service or a copy of IRS Letter 1722 indicating that the student or
parent did not file a return.
d. Documentation of pension, annuity, or unemployment benefits: letter from the applicable agency
showing appropriate year’s total award (if not reported on IRS Forms 1040, 1040A, 1040EZ or 1099).
e. Documentation of Social Security, Supplemental Security Income, or Veterans Administration noneducational
benefits: a letter from the applicable agency showing applicable year’s total award for each
member of the household, including Medicare premiums or IRS Form 1099 for each member of the
household.
f. Documentation of Social Services payments: verification from a branch of the State Office of
Temporary and Disability Assistance, Office of Children and Family Services Assistance, or a county
department of Social Services showing year that benefits were received and names of recipients
including the applicant.
g. Documentation of child support and/or alimony: a court order, affidavit.
h. Documentation of additional members in household: birth certificates, marriage certificates, 3rd
party verification, or similar documentation acceptable to the Commissioner, along with proof of
income or lack of income for each such member.
i. Documentation of zero household contribution: the needs analysis output form from one of the United
States Department of Education.
