2019 Young Innovators Quest Application

YiQ-2019 Application

Health & Science Innovations, Inc.
The Young Innovators Quest (YiQ) will be held by Health and Science Innovations at Indiana University-Purdue University Indianapolis (IUPUI) from June 5-22, 2019, and at Alivio Medical Center from June 24-28, 2019.

To apply, complete this application form and attach a PDF (or JPEG) copy of your official high school transcript and a recommendation letter from a science or math teacher. Please have these two documents ready before starting the application. The application has to be filled in one session.

If you plan on requesting financial assistance, please have your family's tax returns information from the previous year ready.

Health and Science Innovations staff will review applications after the due date of each round of applications, with final decisions made on or before May 15, 2019. Priority will be given to "Early Bird" applicants. The Young Innovators Quest selection process may include an interview. You will be contacted by Health and Science Innovations staff if you are to be interviewed as part of the selection process.

Please complete every section of this application by:

Early Bird Deadline: March 10, 2019, 11:59 p.m.

Regular Deadline: April 20, 2019, 11:59 p.m.

Participant's Information:
Full Name *

First Name Middle Name Last Name
Birth Date *

Month Day Year
Gender *

Male Female
Grade *
Currently in
Phone Number *
E-mail *
Participant's email address.

Home Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Do you participate in a "Free or Reduced Meal" Program? *

Yes No

Parent / Guardian Information:
Under custody of *
Parent Name(s) *
Parent Occupation *
Parent Phone Number *
Parent E-mail *
Other Parent Name(s)
Optional
Other Parent Occupation
Other Parent Phone Number
Other Parent E-mail

References:
Referred by (include how did you learn about this program, name, organization and contact email if available)
High School *

High School Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

High School Phone Number *
High School Counselor *
Recommending Teacher *
Recommending Teacher's email
Science/ Math/ Engineering Courses Completed *
Science/ Math/ Engineering Courses In Progress *
GPA *
GPA Point System *
Is GPA Weighted? *

Tuition and Financial Assistance:
The program fee is $985 per student. This amount represents about 40% of the total cost per student, the other 60% of the cost is covered by grants and donations. From these grants and donations we have created a fund to offset the cost of the program fee for families that cannot afford to pay the full amount. The level of financial assistance will depend on available funding and level of need. Each student may request up to $950 in assistance to offset the cost of the program.

To qualify for financial assistance a family will have to demonstrate financial hardship by providing evidence (e.g. student's participation in free and reduced meals at school, federal income tax returns, any document showing recurring expenses like mortgage, rent, student debt, etc.). We will consider financial assistance for families with a gross income below 200% of Federal Poverty Levels (https://aspe.hhs.gov/poverty-guidelines) and/or students who are currently participating in Free and Reduced Meals programs.

Program fee includes workshops, industry visits, use of laboratory equipment, materials, some meals, and overnight stay at the campus students dorms. The program fee is collected only if and when the student is accepted into the program. Program fee is non-refundable after the program starts.
Payment Option *

I will pay the early-bird fee of $785 (if applying before March 10) I will pay the regular fee of $985 I will pay out-of-state fee of $1,900 I would like to request financial assistance...
Answer the following questions if you are requesting financial assistance:
Number of Persons in Family / Household
Household Gross Income
From your Federal Tex Return or W2 forms
Household Net Income
Gross income minus recurring living expenses (including any student debt, child support, alimony, rent, mortgage, utilities)
Tuition Assistance Request
You may request up to $925 assistance to offset the regular program fee.

Supporting Documents and Certification:
Instructions for Uploaded Documents:

A recommendation letter should answer the questions below, as well as include a statement by your teacher on whether they are interested in serving as your mentor, should you continue your research project throughout the academic year following YiQ summer program. It must also be signed by your teacher and include contact information.

1. For how long have you known the applicant and in what capacity do you know the applicant?

2. How will the applicant benefit from the YiQ program and what do you expect the student to gain from this experience?

3. To what extent and in what capacity has the student shown interest in the fields of science, technology, engineering and mathematics?

Your transcript should include your GPA and class rank, if applicable, and be signed by your guidance counselor. Please make sure your counselor includes contact information.
Science Teacher Recommendation Letter PDF
Must be signed by high school science teacher and include contact information. Letter may also be sent directly to contact@scienceinnovations.org.
Official High School Transcript PDF
Must be signed by high school guidance counselor and include contact information. Transcripts may also be sent directly to contact@scienceinnovations.org.
Signature Conditions

By signing below, I attest that all information included in this application is complete and correct.
Signature

Clear
Enter the message as it's shown *
Health and Science Innovations, Inc.

2060 N. Shadeland Ave., Suite 110 | Indianapolis, IN 46219

Ph: (317) 703-7836 | contact@scienceinnovations.org

www.scienceinnovations.org
Should be Empty:

	Applied	Participated	Did not Participate
YiQ 2013
YiQ 2014
YiQ 2015
YiQ 2016
YiQ 2017
YiQ 2018

	Have no Clue	Know the Basics	Can Manage	Very Skilled	Step Aside I'm a Guru
Creativity
Innovation
Intellectual Property
Scientific Research
Designing / Prototyping
Communications
Leadership
Computers / Tablets
Teamwork/Collaboration
Problem Solving
Project Management
Coding / Programming
STEM Careers
College Life
Resume / Interviews

Participant's Information:

Parent / Guardian Information:

References:

Logistics Information:

Interests and Goals:

Tuition and Financial Assistance:

Supporting Documents and Certification: