Maimonedes Woman in Medicine Application

Last Name _________________   First Name ________________ Middle ____________

Date of Birth_______________  

Home address_________________________________________________________

Home Phone ___________________            Cell Phone ___________________

Email____________________

Parent/Guardian Name______________________________

Parent Phone Number ______________________

Parent email______________________

Grade (Fall 2014)           * Freshman    * Sophomore     * Junior     *Senior

High School____________________________

GPA / Class rank (if known)_____________

Please list Honors/ AP classes you have taken ________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Please state why you think that you should be chosen for this program
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Name of Guidance Counselor___________________

Guidance Counselor Phone Number__________________

Essay (500-word maximum)
Why are you interested in participating in the Maimonides Women in Science Summer Program?