APPLY NOW FOR FALL 2017 SPREP at Columbia University... Due: Septmeber 15, 2017

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. 1 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 2 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: _____________ 3 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. 4 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 5 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 6 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: 7 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. 8 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 9 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.