Application for Participation in PREMAT
for summer 2004. Page 1
Summer Program June 21 to
Circle One: Rising Senior or Graduated Senior coming to CSU or Graduated Senior going to_______________U.
Name:______________________________________________________ High School:___________________________
Address:____________________________________________________ Physics or Chemistry or Biology Teacher (who
will write a short recommendation
City, State, Zip_______________________________________________ _____________________________________
Telephone No.: ______________________________________________ Grade Point Average for HS :_____________
Email address:_______________________________________________ ACT score: __________________________
Social Security No.: ___________________________________________ Planned Major:_______________________
Parent or Person to contact in case of emergency
Name:______________________________________________________
Address:____________________________________________________
City, State, Zip_______________________________________________
Telephone No.: ______________________________________________
Work Telephone No.: _________________________________________
Medical Insurance Information in case of emergency (if available)
(This information is necessary in case of a medical emergency where the student might need to be transported to the emergency room for emergency treatment.)
Policy Name & No.:__________________________________________________
Signature of Parent or Guardian (This signature gives parental permission for the student to participate in the PREMAT program and to benefit from the experience. This signature also authorizes the PREMAT staff to take the student to the emergency room and/or see that emergency personnel are summoned to treat the student in case of an accident or medical emergency.)
Signature:_______________________________________________________
Date:__________________________________________
This application can be sent or faxed to
Professor Samuel Bowen
Dept. of Chemistry and Physics
fax: 773-995-3809
tel: 773-995-3804 or sbowen@csu.edu
Application for PREMAT04 Page 2
In the space below write a short essay answering the questions:
Why you would like to participate in PREMAT04? AND What are your career interests that could lead to biomedical research careers?
(Majors in biology, chemistry, physics, math, psychology, all could lead to careers in biomedical research; interest in science and in doing research will be useful)
The essay should be on this page only and may be hand written. Write your name:________________________________
Return both pages of the application with a letter from a
teacher to S.Bowen, Dept. of Chemistry and Physics,