Official LAST NAME. Please provide your LAST NAME as it appears on your social security card, or other similar official documents. If your last name is more than one word, please include it here with with caps, or no caps the way it appears on your documents -example: de la Vega.
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First and Middle Names. Please provide your first and middle names the way they appear on your social security card, or other similar official documents. First and Middle Name/s:
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School Email. If you have a school issued email, enter here.
enter your email address at school if you have one
Personal Email. IMPORTANT: Make sure the email address you provide here is working for you. This is the email where you will receive the follow up links for your application.
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Personal email address where confirmations are sent
Your personal email again to ensure accuracy.
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This helps ensure accuracy
Please double check your personal email entries - they do NOT match
Phone number where you are best reached?
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(###) ###-####
Name of Parent(s) or Guardian(s) that you live with. If you have a shared custodial arrangement, please add name/s of other custodial parents on the next question.
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Custodial parent/s or legal guardian/s
Name(s) of Additional Custodial Parents or Legal Guardians with shared custody.
Custodial parent/s or legal guardian/s
Home Address. Enter your complete address here, with city, ST and zip
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address
Best phone number where one of your parents can be reached
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If you need to take a break to get your parents email address, choose the 'Save & Return Later' option at the bottom of this form. Please be sure to enter your email into the system so they can send you the form with your saved info.
Parent email. Please provide an email address for the parent/guardian where you live who will complete the parent portion of the application. Please enter the correct email.
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If needed, help your parents create an email account
Parent email 2. If possible, provide an email address for a second parent.
If needed, help your parents create an email account
Which high school do you attend?
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Official School Name
In which COUNTY is your school located?
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Marion Boone Clinton Hamilton Hancock Hendricks Johnson Morgan Shelby Other
County location of your school
In which county is your school located? If your school is outside Indiana, provide the name of the county first, followed by the name of the state where your school is located.
County location of your school
Expected Graduation Year
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2022 2023 2024 Other
graduation year
Please note: ONLY students in grades 10, 11 or 12 are eligible to apply.
Date of Birth
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MM/DD/YYYY - month/day/year
Gender
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Female Male Non-Binary
American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White Multi-Racial Unknown
Choose most descriptive option
Ethnicity
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Not Hispanic or Latino Hispanic or Latino Unknown
Choose most descriptive option
For the summer of 2022 we anticipate most students participating in person with a small virtual program available for students who live more than 40 miles away from the IUPUI / IU School of Medicine campus. Which option best describes your participation interest?
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I am only interested in participating in-person I am only able to participate virtually - online I am happy to participate in any format the internship team decides for me
If accepted for in-person participation, how will you travel to your internship location?
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I will drive my own vehicle I will drive a family vehicle Someone else will drive me I will walk, bike or take bus Because of distance and - or transportation I am not able to participate in-person
Some internship locations may require students to be fully vaccinated. Which option best describes your vaccination status?
I am already vaccinated I anticipated being vaccinated prior to April 1, 2022 Other, please explain
Please provide details regarding vaccination status
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Are you a citizen of the United States?
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Yes No
Are you a Permanent Resident of the United States with a Permanent Resident ''Green Card'' or USCIS Form I-551?
Yes No
Please describe and explain your citizen or immigration status. Please provide sufficient information for program directors to know how to best support you.
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Summer Research Program - IU Simon Comprehensive Cancer Center Future Scientists Program - IU Simon Comprehensive Cancer Center Wells Center - Summer Internship Program Indianapolis Project SEED - American Chemical Society Purdue Project SEED - American Chemical Society Indianapolis Project STEM - Indiana CTSI, IU School of Medicine Physics Program - IUPUI School of Science Your Team Can Decide which program is best for me
Choose Program Best For You
If you're NOT selected for the program you selected above, what are 1-2 other programs you believe would be a good fit for your interests? Explain why.
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No Yes, by race or ethnicity as described in section A Yes, by other factors listed in section C Yes, by other factors and I can provide additional information
Does your background meet the NIH definition of disadvantaged or underrepresented in the biomedical, clinical, behavioral, and social sciences as specified in this NIH notification sections A or C. https://grants.nih.gov/grants/guide/notice-files/NOT-OD-20-031.html
If NO, please write 'no'. If YES, please provide details of how you meet the established criteria.
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Optional Question - Not Required. Does your background meet the NIH definition of disadvantaged or underrepresented in the biomedical, clinical, behavioral, and social sciences as specified in this NIH notification sections A or C. https://grants.nih.gov/grants/guide/notice-files/NOT-OD-20-031.html
If NO, please write 'no'. If YES, please provide details of how you meet the established criteria.
Background Explanation. Please explain how your background meets the NIH definition of disadvantaged or underrepresented in the biomedical, clinical, behavioral, and social sciences as specified in this NIH notification sections A or C : NIH Diversity
If you have problems accessing this link, feel free to copy and paste full link into a different browser: https://grants.nih.gov/grants/guide/notice-files/NOT-OD-20-031.html
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Financial Eligibility for Project SEED - https://www.indyprojectseed.org/financial.pdf . See link with income chart per household number to determine family income eligibility guidelines for Project SEED participation. Based on your family's 2021 family income, which option best describes you?
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YES, I'm sure I qualify for Project SEED YES, I think I qualify for Project SEED Maybe, I do not know for sure if I qualify for Project SEED No, I know for sure I do not qualify for Project SEED
SEED eligibility
How did you first learn of these programs?
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Past Intern Teacher Website Other
Who was the past intern? How do you know each other?
What is the name of the teacher who informed you about these programs?
Explain details of how you learned of these programs
Last summer, 2021, did you participate in either Project SEED, STEM, Future Scientists, Physics or Nanotechnology Programs?
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Yes No
Enter your name on this line to certify you have completed this form with accurate information.
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Type your name here
Submit
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