Rutgers New Jersey Medical School

Science, Medicine and Related Topics (SMART) Summer Program 2024 Application

Thank you for your interest in Science, Medicine and Related Topics (S.M.A.R.T.) at New Jersey Medical School (NJMS).
This application is required of all applicants in order for the file to be processed and reviewed.

Program Dates: Mon-Fri, 9AM- 2PM daily, July 8 - August 2, 2024 Application Check List
Note the program will run Hybrid
The application must be submitted online by Friday, May 17, 2024
All accompanying documentation must be faxed, emailed, or submitted in person by the close of business on Friday, May 17, 2024
Any applications/documentation submitted after the deadlines will be reviewed only if there is space remaining.

Program Tuition: $25 non-refundable application fee. $350, due prior to the start of the program.

Academic Information

Has the applicant participated in any academic enrichment programs other than SMART? Yes No

If yes, please complete the remainder of this section

Program 1

Name of Program:

Program Director:

Phone: () -

Email:

Specify when the applicant participated:

Program 2

Name of Program:

Program Director:

Phone: () -

Email:

Specify when the applicant participated:

Please list and describe any extracurricular activities in which you participate
(include school, community, health research or religiously related activities)

Activity/Description	Dates of Participation

Are you interested in a Health Sciences Career? Yes No Unsure

If yes, which Health Sciences career?

If no, what career do you plan to pursue?

How did you find out about this program?

Emergency Contact

Emergency Contact FILL IN DATA AS COMPLETELY AS POSSIBLE

Please provide the name address and phone numbers of one(1) or two (2) people in addition to the primary care givers who may be contacted in the event of an emergency

Contact 1

Name: Relationship:

Address (if different from applicant):

Home Phone: () -

Business Phone: () -

Alternate/Cell Phone: () -

Contact 2

Name: Relationship:

Address (if different from applicant):

Home Phone: () -

Business Phone: () -

Alternate/Cell Phone: () -

Health Information

FILL IN DATA AS COMPLETELY AS POSSIBLE

Please specify medical insurance, if any:

Please indicate if the applicant has any medical conditions that may require urgent/emergent treatment
while attending the SMART Program or would prohibit him/her from participating in any activities (e.g. asthma)

Does the applicant have any food allergies (e.g. peanut butter, shellfish, etc.)? Yes No
(If yes, please note allergen and reaction)

Allergen/Substance	Reaction

Please provide the names and dosages and indication for any EMERGENCY MEDICATIONS
That might need to be given during the course of the SMART Program
(If medication is required parent/guardian/emergency contact will be notified and Emergency Medical Services called if necessary)

Medication Name	Dose	Indication/Reason
Example only: Albuterol Inhaler	Example only: 2 puffs	Example only: wheezing or cough

Personal Statements

Question: Please discuss your motivation for applying to SMART
(minimum 750 characters, maximum 1500 characters)

characters left

Required Accompanying Documentation

ALL ARE REQUIRED, PLEASE PRINT FORMS AND GIVE THEM TO THE APPROPRIATE PARTIES
(Please note that teacher/guidance counselor recommendation form will be emailed to the email address listed below.
Must be official school email. It is your responsibility to follow up with this individual)

Evaluating Science Teacher: Name Email Phone () - Fax () -

Links to Required Documents (Requires PDF Reader) Must be printed and mailed or faxed:
Teacher Recommendation Form
Transcript Release
Supporting Documentation fax/mail cover sheet
Policies and Consents
Payment Remittance Slip

Certification Statement

By submitting this application, I certify that the above information is true and complete to the best of my ability. I have read the policies & consents I understand agree/agree on the behalf of my child to abide by them. I understand that my application will not be reviewed without all accompanying documentation to include the $25 application fee. Please mail check or Money Order to 185 South Orange Ave, B624, Newark, NJ 07101. DO Not MAIL Full tuition until you have been notified of acceptance.

Agree

FILL IN DATA AS COMPLETELY AS POSSIBLE

Parent/Guardian Marital Status:
Single	Married/Domestic Partnership, living together	Married, living separately
Separated	Divorced	Widowed/Widower

If single, married-living separately, separated or divorced, who is the primary guardian?
parent/guardian 1	parent/guardian 2	joint

Highest Level of Education:
some middle school	Associate's Degree
middle school	Bachelor's Degree
some high school	Master's Degree
high school	Doctoral Degree
some college	Other

Highest Level of Education:
some middle school	Associate's Degree
middle school	Bachelor's Degree
some high school	Master's Degree
high school	Doctoral Degree
some college	Other

Sibling's Name	Age	Sex		Currently Applying to SMART	Past SMART Participant
		male	female
		male	female
		male	female
		male	female
		male	female
		male	female