PERSONAL INFORMATION
Name (Last, First, M.I.):
Social Security Number:
Date of Birth:
	Male   Female
Address:
Tel - Day:
Tel - Evening:
E-mail:
ACADEMIC HISTORY
Name, address and telephone number of high school currently attending:
Name of current science teacher:
Telephone No.:
Current grade:	Junior   Senior
Grade point average:
Date of graduation:
Honors and awards:
STATEMENT OF GOALS
Please include below a Statement of Goals, or mail a typed, double-spaced document, stating your research interests, experience, education goals, career objectives and any information which may aid the selection process.
WORK EXPERIENCE
Have you previously participated in an internship program at TSRI?    Yes    No
If yes, name of principal investigator:
Year:
Length of internship program:
Have you participated in a research internship program at another institution?    Yes   No
If yes, name of institution:
Area of work experience:
Year:
Length of internship program:
Funding source:
Other related work experience:
GENERAL INFORMATION
Does your family receive public assistance, food stamps, SSI, SSA or unemployment insurance?    Yes    No
Do you have transportation to The Scripps Research Institute?    Yes    No
Do you have any prior commitments (i.e., vacations, classes, sports) that may conflict with the dates of the spring tutorial or the summer internship program?    Yes    No
If yes, please explain.
Have you applied (or do you plan on applying) for any other summer position(s)?    Yes    No
If yes, where?
Your Ethnicity:   African American   Native American   Caucasian   Native Pacific Islander   Asian   Hispanic   Other   Decline to state