SMS Summer 2022 Research Program Application

Student Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Please check any of the categories below that apply to you

Underrepresented group (see below) Disability (describe below) Low Income (per Federal guidelines - see below)

Please describe your disability:

Date of birth

Date

School

Grade

GPA (unweighted)

Parent or Guardian Name

First Name Last Name

Parent or Guardian Occupation

Parent or Guardian number

Please enter a valid phone number.

Student’s Contact Number

Please enter a valid phone number.

Alternate Contact Number

Please enter a valid phone number.

Student's Email

example@example.com

Parent’s Email

example@example.com

In Case of Emergency, please contact

First Name Last Name

Relation to student

Emergency Contact Phone

Please enter a valid phone number.

Emergency Contact Email

example@example.com

Is student fully vaccinated, with vaccinations up to date including vaccination for Covid-19? Only vaccinated students can be considered due to nature of lab work.

Yes No

Please provide the name, phone and email for an advisor, principal, teacher or professor as a reference:

By signing below, I am stating that all of the above information is true and I understand that if I am selected to participate in the SMS Summer Research Program, I am expected to complete an uninterrupted 8-week assignment in a research lab or program at Baylor College of Medicine between June 2022 and August 2022 depending on the availability of the Principal Investigator. I understand that I will not be allowed to commit to other programs, camps or activities during that time. I understand that as a condition of this position, I am required to prepare and present as per the guidelines above.

Student Signature

Clear

Parent/Guardian Signature (if under 18)

Clear

Underrepresented Groups

The AAMC definition of underrepresented in medicine: "Underrepresented in medicine means those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population."

This includes applicants who are Black, Mexican-American, Native American (that is, American Indian, Alaska Native, and Native Hawaiian), or mainland Puerto Rican.

Disability

A disability will not bar a qualified applicant from selection for the Summer Research program if the applicant is able to perform the essential functions of the lab assignment. If you have a disability you wish to let us know about on your application, please describe your disability in a written attachment.

Low Income

If your family’s income is at 200% or below of the 2017 Federal Poverty Guidelines listed below, please check the “Low Income” section on the application.

Household Size	100%	133%	150%	200%	250%	300%	400%
1	$12,060	$16,040	$18,090	$24,120	$30,015	$36,180	$48,240
2	16,240	21,599	24,360	32,480	40,600	48,720	64,960
3	20,420	27,159	30,630	40,840	51,050	61,260	81,680
4	24,600	32,718	36,900	49,200	61,500	73,800	98,400
5	28,780	38,277	43,170	57,560	71,950	86,340	115,120
6	32,960	43,837	49,440	65,920	82,400	98,880	131,840
7	37,140	49,396	55,710	74,280	92,850	111,420	148,560
8	41,320	54,956	61,980	82,640	103,300	123,960	165,280

The form below is only for students currently in High School at time of application.

Download this form, fill it out and upload it below.

Upload School Form and Biosketch