OUTbio 2022 Scholarship Application Form

OUTbio LGBTQ+ STEM SCHOLARSHIP PROGRAM

Application Deadline - June 15, 2022
Read and follow the instructions carefully prior to submitting your application. Please gather all the materials needed: essays, transcript, letter of reference, and video before filling out this application.
I. Contact Information
Full Name *

First Name Last Name
Home Address : *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Name of Parent/Guardian (this information is only needed if you are completing the application under the age of 18.
Parent/Guardian Address if different from above

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Phone Number : *

Area Code Phone Number
E-mail : *
Where the confirmation will be send to
II. Demographic Info
Birthdate: *

Month Day Year
Age: *
Preferred Pronouns:
Sexual Orientation *
Status at the time of application:

I will graduate in May 2022 I will be an incoming freshman graduating high school prior to 2022 I have attended college but have less than 32 college credit hours I have attended college but have at least 32 or more college credit hours I am a GED graduate with no college credit hours
III. High School Information:
Name of high school *
High School Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Year of High School Graduation or GED: *
Current GPA: *
Cumulative GPA: *
High School activities, community activities, volunteer work, honors, offices held:
Please attach your most recent high school transcript

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IV. College Information

The college must be based in New England (Connecticut, Maine, Massachusetts, Rhode Island, New Hampshire, Vermont)
Name of college (if known) *
City and State *
Planned Degree Major/Concentration *
Expected Notification of Acceptance (evidence of acceptance will be required for award) *
Acceptance Documentation (if available upload here):

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VI. Volunteer Work
Description (Include organization name, dates of service, total hours and the name of contact at organization)
VII. Employment/Activities History
Employment/Activities History (Please list any paid employment and any activities including any leadership roles, if applicable):

0/300
VIII. Essays

Your essay should have a maximum of 300 words. You should address in your essay:
1. What is your career objective and where do you see yourself in the life sciences? (maximum of 300 words)
0/300
2. Have you participated in any LGBTQ+ advocacy organizations, what involvement have you had in them? (max 300 words)
Type a question

0/300
3. What inspires you and why are you choosing your field of study? (max 300 words)
Type a question
4. How would this scholarship impact your educational plans? (maximum of 300 words)
Essay:

0/300
Video

Please submit a link to a short video of less than 2 minutes about yourself
Submit a link from YouTube or Vimeo
Insert URL
Letter of Reference

Letter of Reference – Please provide a letter of reference by someone involved in your activities, employment, schoolwork or LGBTQ community activities.
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IV. Submissions
I declare that my information on the above form is true and correct to the best of my knowledge. I also confirm that in the event that any information provided by me is not true I will forfeit/reimburse the awarded compensation that I received as a result of my providing the erroneous information.

I authorize OUTbio to collect, receive, store, transfer, and use any information provided by me, or any information obtained in connection with this application, and to disclose such information to all participating institutions.

I authorize OUTbio to verify any information provided and obtain available official records from any educational institution attended by me. I understand that OUTbio is not responsible if an institution does not provide these records.

I understand that OUTbio may decline to assess my qualifications if the information required for a valid assessment is not available to OUTbio.

If awarded, I authorize OUTbio to publish and post information about me, including my picture to announce the award on its website and other organization publications.
Signature of Applicant

Clear
Print Name

First Name Last Name
Date

Month Day Year
Date
**If not 18 yo, you must have the application signed also by a Parent/Guardian.
Signature of Parent/Guardian

Clear
Print Name

First Name Last Name
Date

Month Day Year
Date
OUTbio does not discriminate in any program or activity on the basis of race, color, religion, gender, age, national origin, disability, marital status, or any other protected class.
Should be Empty:

OUTbio LGBTQ+ STEM SCHOLARSHIP PROGRAM

I. Contact Information

II. Demographic Info

III. High School Information:

IV. College Information

VI. Volunteer Work

VII. Employment/Activities History

VIII. Essays

Video

Letter of Reference

IV. Submissions