PepVax, Inc.
Takoma Academy
Bioscience Summer Internship
Application
July 8 - 31, 2014
PLEASE PRINT ALL INFORMATION USING BLACK OR DARK BLUE INK.
Application can also be filled and sent completed via email to [email protected].
Application is due on or before May 31, 2014.
Please note that only 20 students will be selected for the internship and therefore, no application will be accepted after May 31, 2014.
Participants will be selected on a rolling basis and therefore, student selection for the program may be closed even before the May 31,
2014 application deadline. It is suggested to apply as soon as possible. In addition, a payment of $500 (plus $200 if high school credit
is being requested) is due by May 31, 2014 in order for a student to hold their placement if accepted. Checks or money orders only are
accepted and are made out to PepVax, Inc.
Name ______________ ______________ ______________ Male _____ Female _____
Last
First Middle Initial
Student ______
Date of Birth
______ ______ ______
*NOTE: All high school applicants
Month
Day Year
must be 16 years of age by the July
School Name _________________________
1,
2014 to participate.
School Address ________________________ __________________ ______ _________
Street
City
State Zip Code
School Telephone Number ___________________ School Fax Number ___________________
Area Code & Number
Area Code & Number
Home Address ________________________ __________________ ______ _________
Street
City
State Zip Code
Home Telephone Number ____________________Applicant’s Cell Phone Number __________
Area Code & Number
Area Code & Number
Preferred E-Mail Address _________________________________________________________________
(please print clearly)
Alternative E-Mail Address _______________________________________________________________
(please print clearly)
T- shirt size (circle one): S M L XL XXL XXXL
PARENT OR GUARDIAN OF STUDENT APPLICANTS –PLEASE READ AND SIGN THE FOLLOWING:
_____________________________________ has my permission to submit this application and, if selected, to participate in the
PepVax, Inc. Takoma Academy Bioscience Summer Internship to be held from July 8 to 31, 2014, at Takoma Academy, 8120 Carroll
Ave. Takoma Park, Maryland 20912
______________________________________________
_______________________________________________
Print Name of Parent/Guardian
Signature of Parent/Guardian
Home Phone Number:______________________
Work Phone Number:________________________
Parent/Guardian’s Cell Phone Number: _________________________ _______________________________
Date
Parent/Guardian’s E-mail Address: __________________________________________
(please print clearly)
___________________________________________________________________________________________________
Signature of Applicant
Date
Student applicants: Please complete Page Two of this application and attach a letter of reference from a teacher, school counselor or
administrator.
Page One of Two
High School Student Applicants Complete This Page
Page Two of Two
Name ______________________________ ______________________________ ______________________________
Last
First
Middle Name
Current School Grade ________
Parent/Guardian 1Name ___________________________ Address _______________________ ______ ____________
Street
State
Zip Code
Parent/Guardian 2 Name ___________________________ Address _______________________ ______ ____________
Street
State
Zip Code
Have you participated in a hands-on learning institute on a previous occasion?*_____ _____
Yes No
If your answer to the above question is yes, please complete the following:
• Name of institute you attended:_________________________________________________________________________________
• Where was the institute held?___________________________________________________________________________________
• When did you attend? ________________________________________________________________________________________
• Name of organization sponsoring the institute: _____________________________________________________________________
• Were you nominated to attend? _____ _____; By whom? ____________________________________________________________
Yes No
 List all math, science, and computer technology courses you will have completed by the end of the 2013 - 2013
school year: _________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
 Why are you applying to participate in the PepVax, Inc.Takoma Academy Bioscience Summer Internship (Use a separate sheet, if
necessary.)___________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
 Are you planning to attend college or other post-secondary school? _________ ________ ___________
Yes
No Not sure yet
 Have you taken any of the college admissions tests yet (e.g., ACT, SAT, PSAT)? ________ ________
Yes
No
 Have you worked in a team or group setting previously? _________ ________
Yes
No
 Does your school have access to the Internet? ________ ________
Yes
No
 Do you have access to the Internet at home? ________ ________
Yes
No
 How do you think your participation in this institute will impact your classroom learning?
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Please attach to Page One
Application is due on or before May 31, 2014
Student applicants must attach a letter of reference from a teacher, school counselor or administrator.
High Schools that are planning to attend 10 th, 11th or 12th grade during the 2014 to 2015 school year are eligible to apply.