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BROOKHAVEN NATIONAL LABORATORY
SCIENCE EDUCATION CENTER
COMMUNITY SUMMER SCIENCE PROGRAM


To the Student: Please submit this form along with (1) a one-page statement describing your interest in science, career goals, college plans and reasons for wanting to participate in this program; (2) an official copy of your transcript (see attached instructions to guidance office); and (3) two letters of reference (see attached instructions to references). All materials should be forwarded to:

 Catherine Osiecki
 Brookhaven National Laboratory
 Building 438, PO Box 5000
 Upton, NY 11973-5000
 (631) 344-3054
 (631) 344-5832 fax

Personal Information

Name______________________________________________

Address____________________________________________

___________________________________________________

Telephone __________________________________________

Parent/Guardian _____________________________________

Birth Date __________________________________________

U.S. Citizen? YES NO

PRA? YES NO

If PRA, complete the following:

Birth Country _______________________________________

Birth City __________________________________________

PRA Number _______________________________________

References

1._________________________________________________

2. ________________________________________________

Email Address _____________________________________

Academic Information

High School _________________________________________

Address ____________________________________________

___________________________________________________

Present Grade ______________________________________

List Courses Completed and in Progress.
**Indicate any AP Courses

Science Courses Completed

Physics ___________________________________________

Biology ____________________________________________

Chemistry __________________________________________

In Progress _________________________________________

Math Courses Completed ______________________________

____________________________________________________

In Progress__________________________________________

Computer Courses Completed/In Progress

____________________________________________________

____________________________________________________

Signature ______________________________________________________ Date _________________

 

Parent/Guardian Signature ________________________________________ Date _________________
note: BNL does not provide transportation for the student.

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Last Modified: January 31, 2008
Please forward all questions about this site to: Sarah Maine


DOE, Office of ScienceOne of ten national laboratories overseen and primarily funded by the Office of Science of the U.S. Department of Energy (DOE), Brookhaven National Laboratory conducts research in the physical, biomedical, and environmental sciences, as well as in energy technologies and national security. Brookhaven Lab also builds and operates major scientific facilities available to university, industry and government researchers. Brookhaven is operated and managed for DOE’s Office of Science by Brookhaven Science Associates, a limited-liability company founded by Stony Brook University, the largest academic user of Laboratory facilities, and Battelle, a nonprofit, applied science and technology organization.

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