Stand Alone Online Application Application for Institute on Neuroscience (ION) Application for Institute on Neuroscience (ION) Personal Data First Name * Middle Name Last Name * Home Address * Street Number and Street Name Home Address, cont'd Apartment Number, Suite Number, Etc. Home Address City * Home Address State * Home Address Zip Code * Phone Number * Main Contact Phone Number Email Address * Date of Birth * (mm/dd/yyyy) Age as of June 4, 2018 * 16 17 18 19 Gender Identification * Female Male Prefer Non Binary Language Self-Identification of Race/Ethnicity This program is subject to certain nondiscrimination and affirmative action record keeping and reporting requirements which require us to invite applicants to voluntarily self-identify their race/ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable federal laws, executive orders, and regulations, including those which require the information to be summarized and reported for civil rights purposes. When reported, data will not identify any specific individuals. We are an organization that values diversity and encourages women and minorities to apply. The definitions for each category have been established by the federal government. Please mark the one box that describes the race/ethnicity category with which you primarily identify. Invitation to Self Identify * Hispanic or Latino: a person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race. White: a person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American: a person having origins in any of the black racial groups of Africa. Asian: a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Native Hawaiian or Other Pacific Islander: a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. American Indian or Alaska Native: a person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. I do not wish to disclose. Educational Information Current Grade in School (Note: Minimum age for program is 16) * 9th 10th 11th 12th Projected Date of Graduation (Month/Year) * Name of High School * Address of High School * City, State, Zip of High School * Current Cumulative GPA (based on 4.0 scale) * Scores for PSAT, ACT, and/or SAT * List all Advanced Placement, Honors, or other College-Level Courses You Have Completed Activities, Honors, Awards Are you a member of the Science National Honor Society? * Yes No Name of SNHS Chapter and Advisor Have you participated in any science-related special events such as Brain Bee, Atlanta Science Festival, or Science Olympiad? Yes No Names of special events with descriptions and dates: Names of any honors or awards you have received in high school (science-related listed first) with descriptions and dates: Other If you have any laboratory experience, please describe the work, location, and time frame: How did you learn about the ION Summer Research Program? * High School Science Teacher Other High School Teacher High School Counselor Internet Search for Summer Programs in Neuroscience Internet Search for Summer Science Programs Internet Search for Summer Programs Internet Search for Programs in Neuroscience Former ION Scholar Atlanta Regional Brain Bee The Neuroscience School at GSU (Summer Short Courses) Flyer Social Media (Facebook, Twitter, or Instagram) Other If Applicant is under 18 years old, Parent/Guardian Electronic Signature With Date and Email Address: Documents to Upload or Email Your application will be considered incomplete without the following being received by the deadline: Personal Statement - In no more than 400 words, describe how a summer research experience in neuroscience will contribute to your educational and professional goals. Please format your statement with double spacing. Filename format: LastName.FirstName.PersonalStatement.pdf. Preference is for documents to be uploaded in PDF Format. Your signature on the document indicates your sole authorship. Uploading Files. Please Wait. Drop a file here or click to upload Choose File Maximum upload size: 52.43MB Resume - Please upload your current resume. Filename format: LastName.FirstName.Resume.pdf. Preference is for documents to be uploaded in PDF Format. Drop a file here or click to upload Choose File Maximum upload size: 52.43MB Letter of Recommendation from a High School Science Teacher sent by recommender via email to ION@gsu.edu * Name of Science Teacher and School Leter of Recommendation from an adult not related to you (Examples: Teacher, School Counselor, Job Supervisor, Extracurricular Activity Sponsor) sent by recommender via email to ION@gsu.edu * Name of Individual Sending Letter of Recommendation and relationship to you Official High School Transcript sent via email to ION@gsu.edu or via Mail to ION Summer Research Program, Center for Behavioral Neuroscience, PO Box 5090, Atlanta, GA 30302-5090 * In what format shall we expect to receive your current official high school transcript? (Examples: Sent via mail by the school registrar, Sent via email by the school registrar, Sent via email by a service such as Parchment) Application Fee of $25 Your application will be considered incomplete without the receipt of the application fee by the deadline. Please make your secure payment through Georgia State University's Marketplace (Store name: The Center for Behavioral Neuroscience). You can copy and paste the following URL into your browser, https://secure.touchnet.com/C20797_ustores/web/store_main.jsp?STOREID=204&SINGLESTORE=true, or find the Application Fee Payment Link on the ION website. Application Deadline - 2/4/2018 All applications must be received no later than midnight (EST) on Sunday, February 4, 2018 (including online form, uploaded personal statement, letter of recommendation from a high school science teacher, letter of recommendation from an adult not related to you, official high school transcript, resume, and application fee of $25).