2020 STEPS application

(2023-24) Successfully Training and Educating Pre-Medical Students (STEPS) Program Application

I. DEMOGRAPHICS

First Name:

MI:

Last Name:

Current Address:

City:

State:

Zip Code:

Email Address:

Primary Phone:

Alternate Phone:

Gender:

MaleFemale

Date of Birth:

MonthDayYear

How did you hear about our program?

II. EDUCATION

University/College Name:*

Classification:*

City:

State:

Degree:*

Major:*

Minor:*

Anticipated Graduation Date:

Current Biology, Chemistry, Physics, and Math GPA:

minimum of 3.25 GPA required

Please Attach a Copy of Your College Transcript:

Please explain any special circumstances you would like to be known in considering you for the STEPS Program (e.g. personal learning/physical disability, lengthy family illness, disabled parent, etc.):

Name:

Relationship:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Work Phone:

E-mail:

III. STUDENT PROFILE

Extracurricular Activities: List the extracurricular activities you have been in or are currently involved with and provide a description of your contribution to that activity. Also provide the calendar year(s) in which you participated in each activity.

Service (voluntary or paid): List your volunteer or paid work experience. Explain your specific responsibilities and date(s) completed or currently working.

Honors/Awards (BE SPECIFIC): List honors and awards you have received. Please do not list involvement in organizations and clubs unless you have been elected to an office or selected for a specific honor. Do not abbreviate award names, for example: National Honor Society - NHS. Also include the year(s) in which you received the honor or award.

Writing Entry: Include a personal essay of 500 words or less about your background, interests, and goals. This allows the application review committee to get a better understanding of the student's personality and expectations. Please double-space your writing entry and attach here.*

IV. STUDENT CONSENT AND AGREEMENT

By my digital signature below, I hereby certify that the information provided on this application and attachments I have provided is true and accurate to the best of my knowledge and that the writing entry is my original work. I commit myself to abide by the rules and expectations of the STEPS Program.

Signature

Full Name

First NameLast Name

Date:*

MonthDayYear

V. Teacher recommendations

This letter of recommendation should be on offical letterhead, physically signed by the reference, and include their direct contact information.

Please have this letter sent directly from your teacher to Whitney Cornette at whitney.cornette@st-claire.org. Your application will not be considered complete until recieved.

If you'd prefer to call and offer a verbal reference, please call 606-783-6435.

Emergency Contact