2016 MINI COURSE APPLICATION FORM
RESEARCH SKILLS MINI COURSE AT MSU BOZEMAN (IN ASSOCIATION WITH AIRO)
JUNE 6– JUNE 10, 2016
CHRISTA MERZDORF AND JENNIFER FORECKI
513 LEON JOHNSON HALL
MONTANA STATE UNIVERSITY, BOZEMAN, MT 59717
DEADLINE: March 10, 2016
This application is for the laboratory skills introductory course that is coupled with the Bridges Program.
Applicants using this form wish to apply for participation in just the one-week laboratory skills
course and NOT the remainder of the Bridges Program. In this course, students will learn how to plan,
conduct and communicate scientific research. The course will also cover basic laboratory practices, the
scientific method, and students will learn important laboratory and microscopy skills. Food and lodging
(from evening of June 5 until morning of June 11) will be covered by the course and gas money will be
reimbursed.
Please contact Christa Merzdorf or Jennifer Forecki with questions. The Bridges Program Coordinators
will also be able to answer some of your questions.
Return application packet to Christa Merzdorf or Jennifer Forecki:
Bridges Program Coordinators:
Aaniiih Nakoda College: Brian Grebliunas
Blackfeet College:
Steve Durtka
Chief Dull Knife College: Mary Noel
Ft Peck College:
Paula Firemoon
414-803-1699
Little Big Horn College: Neva Tall Bear
Salish Kootenai College: Christina Rush
Stone Child College:
Larry Gomoll
Christa Merzdorf and Jennifer Forecki:
513 LEON JOHNSON HALL
MONTANA STATE UNIVERSITY, BOZEMAN, MT 59717
FAX NUMBER: 406-994-7077
Jen Forecki:
jforecki@gmail.com
Christa Merzdorf: merzdorf@montana.edu
Phone: 406-994-5645
1.
Name:
(Last)
2.
(First)
Birthdate:___________________
3.
(Middle)
Banner ID: __________________________
(MSU-AIRO Office use only)
4.
6.
 Female
 Male
5. Tribal Affiliation:
Permanent Address:
(Street / PO Box)
7.
Contact Number (Include Area Code):
Please provide the most reliable phone number(s).
8.
(City, State)
Email address:
___________________
HOME
_____
Please provide the most reliable email.
9.
Tribal College:
(Zip)
10.
Major:
11.
Date of your expected graduation from Tribal College:
12.
Four-year university you plan to attend:
13.
Intended major at four-year university:
14.
Please list any coursework completed in math or science and grades received:
CELL
2016 APPLICATION FORM (Page 2)
RESEARCH SKILLS MINI COURSE AT MSU BOZEMAN
JUNE 6 – JUNE 10, 2016
CHRISTA MERZDORF AND JENNIFER FORECKI
LEON JOHNSON HALL
MONTANA STATE UNIVERSITY, BOZEMAN, MT 59717
15. Housing: Housing will be in the MSU dorms from Sunday, June 5, until Saturday, June 11. It is not
possible to provide family housing for one week. Thus, please expect to make your own arrangements for
your children back home (or in Bozeman, should you have family or friends).
I am able to come on my own and will stay in the dorms.
yes
no
I am able to provide my own housing (you will receive travel money and a food allowance)
yes
no
16. MSU REQUIRED SAFETY & SECURITY INFORMATION (All applicants must complete this section.)
1. Have you ever been convicted of a felony (please include instances of deferred sentencing)?
A felony in Montana State law is defined as a crime for which more than one year in prison may be
imposed.
2. Have you ever been subjected to court-ordered confinement for threatening or causing physical or
3. Have you ever been disciplined, suspended from, or placed on probation at any educational institution
f
Suspension is defined as a sanction imposed for disciplinary reasons that results in a student leaving
school for a specified time period. Dismissal from a college for disciplinary reasons is defined as
permanent separation from an institution of higher education on the basis of conduct or behavior.
4.
NOTE: Answering “Yes” to any of these questions will not automatically prevent admission, but you will
be asked by the university to provide additional information. This information will be reviewed by a
campus committee to ensure campus safety. Any falsification or omission of data may result in a denial of
admission or dismissal.
17. What is your general area of interest?

Agriculture

Cell Biology and Neuroscience

Engineering

Microbiology

Environmental Science

Immunology & Infectious

Natural Resources

Biology

Fish & Wildlife

Community Health

Biofilm Engineering

Psychology

Other:
Diseases
2016 APPLICATION FORM (Page 3)
RESEARCH SKILLS MINI COURSE AT MSU BOZEMAN
JUNE 6 – JUNE 10, 2016
CHRISTA MERZDORF AND JENNIFER FORECKI
LEON JOHNSON HALL
MONTANA STATE UNIVERSITY, BOZEMAN, MT 59717
18. Please tell us about yourself, including your career interests and goals, why you want to participate in
the research skills mini course, and your interest in pursuing a career in science or engineering. Include
any academic and/or personal achievements and how these relate to your goals. (You may include
additional pages if necessary.)
19.
Submit transcripts from all colleges you have attended.
20.
Submit two recommendations, each completed by an instructor or college counselor (both
recommendation forms are attached).
21.
Your application packet must be completed and submitted to Jennifer Forecki or Christa
Merzdorf (see address or fax number at the top) by March 10, 2016.
22.
Please call 406-994-5645 or send an email to Jennifer Forecki jforecki@gmail.com or Christa
Merzdorf at merzdorf@montana.edu if you have any questions about the course or the
application.
STUDENT WAIVER FORM FOR 2016 SUMMER
RESEARCH SKILLS MINI COURSE AT MSU BOZEMAN
JUNE 6 – JUNE 10, 2016
CHRISTA MERZDORF AND JENNIFER FORECKI
LEON JOHNSON HALL
MONTANA STATE UNIVERSITY, BOZEMAN, MT 59717
A. This section is to be filled out by student (print or type name):
NAME:
Under the provisions of the Family Educational Rights and Privacy Act, you may decide whether letters of reference
are to be held confidential or are to be available for your personal inspection. Please sign one of the following
statements:
□I DO NOT WAIVE my right of access to the form. It shall be made available to me for inspection upon written
request.
□I DO WAIVE my right of access to this form and grant permission for it to be held confidential.
___________________________________________
(Signature of applicant)
STUDENT RECOMMENDATION FORM FOR 2016 MINI COURSE
ONE-W EEK RESEARCH SKILLS MINI COURSE AT MSU BOZEMAN
JUNE 6 – JUNE 10, 2016
CHRISTA MERZDORF AND JENNIFER FORECKI
LEON JOHNSON HALL
MONTANA STATE UNIVERSITY, BOZEMAN, MT 59717
A. This section is be filled out by the tribal college instructor or counselor recommending the student.
A
Excellent
B
Good
C
Average
D
Poor
E
Don’t Know
A
B
C
D
E
1. INITIATIVE: Promptness, perseverance, self-discipline.
2. MOTIVATION: Seriousness, interest, commitment.
3. MATURITY: Common sense, sound judgment, decision-maker.
4. COMMUNICATION SKILLS: Oral expression, writing ability.
5. ABILITY TO LEARN: Potential for growth, self-development
6. SCIENCE BACKGROUND
7. MATH BACKGROUND
8. ATTENDANCE AND PUNCTUALITY: Observance of requirements.
9. FLEXIBILITY: Team-player, open-mindedness.
B. For Student Evaluators:
Please comment in the space below on the research skills mini course applicant’s academic
performance; experience in STEM fields; career goals; motivation; and readiness to participate in an
intensive one-week research skills mini course that is held at MSU-Bozeman. (You may include
additional pages if necessary.)
Print Name of Tribal College Faculty or Counselor
Tribal College
STUDENT RECOMMENDATION FORM FOR 2016 MINI COURSE
ONE-W EEK RESEARCH SKILLS MINI COURSE AT MSU BOZEMAN
JUNE 6 – JUNE 10, 2015
CHRISTA MERZDORF AND JENNIFER FORECKI
LEON JOHNSON HALL
MONTANA STATE UNIVERSITY, BOZEMAN, MT 59717
A. This section is be filled out by the tribal college instructor or counselor recommending the student.
A
Excellent
B
Good
C
Average
D
Poor
E
Don’t Know
A
B
C
D
E
1. INITIATIVE: Promptness, perseverance, self-discipline.
2. MOTIVATION: Seriousness, interest, commitment.
3. MATURITY: Common sense, sound judgment, decision-maker.
4. COMMUNICATION SKILLS: Oral expression, writing ability.
5. ABILITY TO LEARN: Potential for growth, self-development
6. SCIENCE BACKGROUND
7. MATH BACKGROUND
8. ATTENDANCE AND PUNCTUALITY: Observance of requirements.
9. FLEXIBILITY: Team-player, open-mindedness.
B. For Student Evaluators:
Please comment in the space below on the research mini course applicant’s academic performance;
experience in STEM fields; career goals; motivation; and readiness to participate in an intensive
one-week research skills mini course that is held at MSU-Bozeman. (You may include additional
pages if necessary.)
Print Name of Tribal College Faculty or Counselor
Tribal College