SRPYP 2024 Student Application

SRPYP 2024 Student Application

Scientific Research Preparatory Yearlong Program
The Scientific Research Preparatory Yearlong Program (SRPYP) was designed to help resolve the underrepresentation of AI/AN in the health professions. As such the overarching purpose of the program is twofold: (1) motivate students to consider careers in STEM and health sciences and serve in their communities in areas where the need is greatest; and (2) prepare AI/AN from the Yakama Nation, other Tribal Nations and Latinos living to participate in the NIH Summer Internship Program in Bethesda, Maryland. The proposed yearlong program addresses health disparities and prepares AI/AN and Latinos to develop skills in healthcare research through both didactic and laboratory sessions. The program teaches the science concepts within the domains of chemistry, biology, immunology, endocrinology, human anatomy, and neuroscience. Integral to this curriculum is the incorporation of Native American and Hispanic values and traditions in lessons through the participation of Elders, Traditional Knowledge Scholars, and teachers.

Program runs Monday - Friday starting June 24 - August 9, 8:30am - 4pm(time subject to change depending on curriculum).

Eligibility Criteria: (must meet all three categories)

- 16 years of age or older, and
- are a junior or senior in high school, in good academic standing for the 2023-24 school year; we may require copies of unofficial transcripts
- are U.S. citizens or permanent residents, and have the supported documentation, i.e. birth certificate, passport and social security card (needed to process stipend payment at the end of the program)

If you have any questions, please contact srpyp@pnwu.edu
Applications due June 20th
Student Information
Student Name*

First NameLast Name
Student Date of Birth *

MonthDayYear
Date
School you are currently attending is*
Grade entering in 2024-2025 school year*
Gender

MaleFemaleLGBTQIA+Prefer not to say
Ethnicity*

Indigenous/Native AmericanBlack/African AmericanLatinx/HispanicAsian/Pacific IslanderOther
Tribal Affiliation
If affiliated with a tribe, which one?
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you currently reside in the homelands of the Yakama Nation or other indigenous homeland?*

YesNo
If you responded yes to the previous question, which one?
Student Phone Number*
Please enter a valid phone number.
Student Email*
example@example.com
Have you been participating in any other extracurricular activities or academic activities?*

Band/Orchestra/ChoirCultural Experiences and activitiesLeadershipClubAssociated Student Body (ASB)AthleticsCommunity ServiceRunning StartInternational Baccalaureate(IB)HonorsAdvanced Placement (AP)Dual Credit ClassesCollege Readiness (College Success Foundation, AVID Program)EmployedOther
Have you participated in the Summer Research Preparatory Yearlong Program (SRPYP) before? If so, which years?*
Have you participated in the Roots to Wings program before? If so, which years?*
Additional Eligibility
Because the program may be online, hybrid, or in person, please let us know how you will be able to commit to participating.*
Why are you interested in the SRPYP 2024-25 Program?*
What do you hope to learn or gain from the SRPYP 2024-25 Program?*
Are you interested in the health sciences field? If so, which professions?*
Why should we choose you for the SRPYP 2024-25 Program?*
What additional comments or information you would like to share with us to support you if chosen to participate?*
Student Commitment
SRPYP sessions run from June 2024 - August 2024, Monday through Friday, then after closing ceremony in August the program continues until January 2025. Please carefully consider the following statements before making a commitment to this program:

1. I will attend all sessions and when unable to attend, I will notify the program beforehand via email and will present a signed excuse letter from my caregiver.
2. I will be respectful, responsible, and safe.
3. I will engage and particiapte in my learning and contribute positively to the learning of others.
4. I will adhere to all school and PNWU rules, expectations, and group norms.

I understand I may not be able to participate if I am unable to fulfill my commitments.
Signature*

Clear
W-9
In order for you to receive your "Participation Stipend," you need to complete a W-9 form and upload it here.

You can download a W-9 form by going to https://www.irs.gov/pub/irs-pdf/fw9.pdf
Upload a signed copy of your W-9 form or send to srpyp@pnwu.edu*

Cancelof
Parent/Legal Guardian Information
Parent/Legal Guardian Name*

First NameLast Name
Parent/Legal Guardian Phone Number*
Please enter a valid phone number.
Parent/Legal Guardian Email*
example@example.com
Parent/Legal Guardian Consent*

I understand the commitment my child is making and my commitment to ensure my child’s participation. I understand it is my responsibility to ensure my son/daughter attends school and the program. On the days of the program. I understand it is my responsibility to ensure my child is picked up at the designated spot and time after program. In addition, I give permission for my son or daughter to be photographed or videoed during the Scientific Research Preparatory Yearlong Program (SRPYP) activities for educational purposes. With this agreement, I give permission for my child to apply to the Scientific Research Preparatory Yearlong Program (SRPYP).
Photography Consent*

I am granting permission for my child/minor to be photographed. I understand that all photographs submitted become the property of Pacific Northwest University of Health Sciences. I also agree that the photographs may be published in educational books (including electronic versions), supplemental products, and related advertising material, and I understand that there will be no compensation.
Signature

By typing my name below, I acknowledge that I have read and give my consent for the statements above.
Parent/Legal Guardian Name*
Should be Empty:

SRPYP 2024 Student Application

Applications due June 20th

Student Information

Additional Eligibility

Student Commitment

W-9

Parent/Legal Guardian Information

Signature