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?
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