Students on the Forefront of Science
Application Form for 2011 Program
DUE Tuesday February 1, 2011 to Dr. Krivacek
Personal Information:
Last name _________________
First name _______________________
Birth date __________________
E-mail address ____________________
Permanent home address __________________________________________________
Number and Street
________________________________________________________________________
City or Town
State
Zip Code
Parent’s name(s) _________________________________________________
Home phone number ______________
Parent alternative phone number _____________
List all other schools, including summer schools and programs you have attended
beginning with 7th grade.
Name of School
_____________________________
_____________________________
_____________________________
Location (City, State)
Date Attended
________________________ _______________
________________________ _______________
________________________ _______________
Year entering Brooks School: 20____
Advisor Name ________________________
Academic Profile
In the table below, please list the science courses you have taken since Third Form year and
end-of-year grades for these classes (include this year’s course and first quarter grades):
Form Year (3rd, 4th, or 5th)
Course
End of Year Grade
Complete the following sections ONLY if you have already taken the tests
SAT II Subject Tests
__________ ___________ __________
__________ ___________ __________
Date Taken
Subject
Score
__________ ___________ __________
Date Taken
Subject
Score
AP Tests
__________ ___________ __________
Date Taken
Subject
Score
Date Taken
Subject
Score
__________ ___________ __________
Date Taken
Subject
Score
__________ ___________ __________
Date Taken
Subject
Score
Complete the following questions in the space provided or on a separate piece of paper.
List any jobs or extra curricular activities that you have been involved with during the
past three or four years:
Nature of work
____________________________
Employer or Business
___________________________
Dates
Hours/week
______________ ___________
____________________________
___________________________
______________ ___________
____________________________
___________________________
______________ ___________
____________________________
___________________________
______________ ___________
Internship Interests
For Summer 2011, SFS will be offering four internship opportunities. The descriptions
of these are outlined in separate documents. Please rank the internships that interest you.
1-the most desired; 4-the least desired (you do not have to rank ones if there is little
interest).
MGH Perioperative Medicine (Cancer)
MGH Perioperative Medicine (Anesthesia)
Pervasis Therapeutics Biotechnology
Tufts Orthopedics
Satcon Technology
Personal Response
Describe your passion for science. What course here at Brooks or experience beyond
Brooks helps to describe and demonstrate this passion?
What extracurricular activities do you find engaging? What is your favorite nonacademic
activity?
Describe a specific situation where you felt that you were able to demonstrate
independent initiative and curiosity in an academic setting (ie. the motivation and
direction were originated and developed from within).
What aspects of your personality will you rely on in order to find success in an
atmosphere where you may not always have direct supervision and yet are still expected
to perform at a high level?
List the names of two personal references (who are not immediate family) and their
contact information
Name
_________________________
Relationship
Telephone
Email
___________________ ______________ ____________________
_________________________
___________________ ______________ ____________________
Is there any other relevant information that you wish to share with us regarding your
application? You may also choose to expand on any of the above questions in this space.