2016-2017 Application for Student Lab Assistant/Research Program
Complete Sections 1-4 below then submit to your current science teacher who will complete Section 5.
All completed applications must be submitted by February 26, 2016 for consideration. Incomplete
applications will not be accepted.
Section 1 – Personal Information
Last Name: ________________________ First Name: _____________________ Middle Initial: _______
Preferred Name:__________________ Phone: ________________ Email: ________________________
Grade Level in 2014-2015: ________ Advisement Teacher:________________ Room Number:________
Parent/Guardian Information:
Name: __________________________ Phone: ________________ Email: ________________________
Name: __________________________ Phone: ________________ Email: ________________________
Section 2 – Academic and Extracurricular Information
Science Courses Taken:
Science Course
Year Taken
Teacher
Grade (give 1st semester
average if you are
currently taking this
course)
List the non-science extracurricular activities in which you are currently involved (clubs, honor societies,
volunteer work, athletics, etc.).
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you ever or are you currently involved in science-related extracurricular activities? If so, list them.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Will you be participating in IE2 for the 2016-2017 school year? If so, which periods? ________________
_____________________________________________________________________________________
Section 3 – Program Expectations
Initial next to each item and sign at the bottom of this section indicating your understanding of the
requirements for participation in this course. Your parent/guardian also must sign.
_____ I understand that I am required to develop a research paper for presentation to the scientific
community and various science competitions, including but not limited to the regional science
fair.
_____ I understand that participation in the regional science fair and at least four other sanctioned
science competitions is required as part of my course grade.
_____ I understand that I will be required to meet specific deadlines in the development of my
research project. My grade in the course will be determined by my mentor teacher’s
assessment of my progress.
_____ I understand that I am required to complete a brief summer assignment identifying my research
topic of interest.
_____ I understand that I will be required to assist in the preparation of various laboratory activities for
a variety of science courses.
_____ I understand that I will be required to submit regular scientific journal article abstracts.
_____ I understand that I will participate in lessons designed to develop my skills in the laboratory.
_____ I understand that I must follow all science department safety guidelines and complete an online
laboratory safety certification program.
_____ I understand that I will be required to maintain a research portfolio. This portfolio will
determine my grade in the course.
_____ I understand that the school attendance policy applies to this course.
_____ I understand that, in my capacity as a laboratory assistant, I may have access to confidential
information. Any breach in confidentiality will result in my immediate removal from the class.
_____ I understand that my enrollment in this course will be based on previous coursework, grades in
both math and science, teacher recommendation, science department scheduling needs, and
personal work ethic. All decisions made regarding my participation are final and not subject to
the course waiver process.
_____ I waive my right to review the recommendations used in the decision-making process.
Student Signature: ______________________________________________ Date: __________________
I, ______________________________, am the parent/guardian of _____________________________
and understand the above expectations regarding my child’s involvement in the Student Lab
Assistant/Research program.
Parent Signature: _______________________________________________ Date: __________________
Section 4 – Personal Statement
In 150 words or less, explain why you want to participate in the Student Lab Assistant/Research
Program. What do you hope to gain by participating in this class next year?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Rank the following science courses according to your level of interest: Biology, Chemistry, Environmental
Science, Forensics, Physics.
1-
2-
3-
4-
5–
In 150 words or less, describe the science fair project you are considering for your independent
research. NOTE: All projects utilizing microorganisms must be completed in a university lab setting.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
If you are selected, what course would you want dropped from your schedule and replaced with
Scientific Research 3/4? _________________________________________________________________
Section 5 – Current Science Teacher Recommendation
Your teacher will submit the completed application to the science department chair for consideration,
so make sure everything in Sections 1-4 is complete prior to submitting to your teacher.
Rate this student in the following areas (1 = below average, 2 = average, 3 = above average, 4 = one of
the best ever taught):
Integrity
1
2
3
4
Responsibility
1
2
3
4
Scientific Promise
1
2
3
4
Interest in Science
1
2
3
4
Maturity
1
2
3
4
Have you verified the students’ grade information in Section 2? yes / no
Would you recommend this student for participation in this program? yes / no
Additional Comments: __________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Signature: ____________________________________________ Date: __________________________