2023 OUTbio +STEM Scholarship Application Form

OUTbio LGBTQ+ STEM SCHOLARSHIP PROGRAM

Application Deadline - June 30, 2023
Read and follow the instructions carefully prior to submitting your application. Please gather all the materials needed: essay, transcript, and letter of reference before filling out this application.
I. Contact Information
Full Name*

First NameLast Name
Home Address :*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
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

CityState / Province

Postal / Zip Code
Primary Phone Number :*

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

MonthDayYear
Age:*
Preferred Pronouns:*
(he/him | (she/her)| (they/them)
Sexual Orientation*
Status at the time of application:

I will graduate in May 2023I will be an incoming freshman graduating high school prior to 2023I have attended college but have less than 32 college credit hoursI have attended college but have at least 32 or more college credit hoursI 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

CityState / 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)

0/300
VII. Employment/Activities History
Employment/Activities History (Please list any paid employment and any activities including any leadership roles, if applicable):

0/300
VIII. Essay

Please write a short essay on one of the following topics.
Please write a short essay summarizing your experiences or interests in any of the following topics 1) Career objectives in the life sciences, 2) LGBTQ+ activities and advocacy, 3) Your academic interests and rationale for your field of study, OR 4) Impact of scholarship on your academic plans. (500 words)
0/500
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 NameLast Name
Date

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

Clear
Print Name

First NameLast Name
Date

MonthDayYear
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. Essay

Letter of Reference

IV. Submissions