Fillable Bridges To Baccalaureate Application - 2015

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Bridges To Baccalaureate Application - 2015

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Long Beach Bridges to the Baccalaureate (LB3) Program
California State University, Long Beach
Summer Undergraduate Research Opportunity for Long Beach City and Cerritos College Science Majors
LB3 Program: Application
Application Deadline: Friday, February 27
th
2015 by 4:00pm
Application Procedure and Checklist
To apply for the LB3 program, you must complete all the steps below and submit all of the documents listed below:
Step 1 - Read over Program Description, Requirements and complete Bridges Application (Pages 1, 2 & 3)
Step 2 - Include a 2-page (max) narrative describing the following:
Your academic preparation in science and mathematics. What motivated you to select a science major?
Describe your transfer plans after community college (i.e. schools you plan to transfer to and plans for graduate study)
Describe your short and long term career goals. How might Bridges help you achieve these goals?
Describe what you hope to gain from your participation in the Bridges program
Step 3 - Provide one (1) copy of transcript from each institution attended (unofficial copies are acceptable)
Step 4 - Request two (2) recommendations from separate individuals using the Bridges to the Baccalaureate
Recommendation Form provided.
- Note: At least one of the recommendations must be from a faculty member in your major.
- These recommendation letters should address following:
o Your academic/professional achievement(s).
o Your potential for becoming a scientist and/or researcher.
Step 6 - Submit your completed application packet to your campus liaison; see information below
Program Description:
The Bridges to the Baccalaureate Program (LB3) is funded by the National Institutes of Health to increase
the number of underrepresented/ underserved students who transfer to four-year institutions and engage
in biomedical research.
Students conduct FULL-TIME summer research for the duration of the LB3 Program with a CSULB
chemistry or biological science faculty mentor from **June 11
th
, 2015 through August 7
th
, 2015**
Students will earn an hourly wage for 40 hours work per week for the duration of the LB3 program.
Participate in the program’s professional development seminars and career mentoring activities.
Admissions Requirements:
Have completed 24 semester units with a minimum 2.50 GPA
Must be a U.S. Citizen or Permanent Resident
Successful completion in some general science courses
Biology and Chemistry majors preferred
Member of underrepresented/underserved student populations
o (see NIH definition: http://grants.nih.gov/grants/guide/pa-files/PAR-11-285.html - participants)
Cerritos College:
Matt Covill - Biology Department
mcovill@cerritos.edu; Office: S-115
Linda Waldman - Chemistry Department
lwaldman@cerritos.edu; Office: S-213
Long Beach City College:
Mary Perrot - Physical Science Department
mperrot@lbcc.edu; Office: D344
Mehrzad Akhavan, Life Sciences Department
makhavan@lbcc.edu; Office: D249
Long Beach Bridges to the Baccalaureate (LB3) Program
California State University, Long Beach
Summer Undergraduate Research Opportunity for Long Beach City and Cerritos College Science Majors
LB3 Program: Application
Personal Information: (Print/ Type) Bridges Application - Page 1
Demographic Information: (Please indicate ALL the categories you identify with below)
Other Personal Information:
□ Yes □ No - Do you and your family qualify under 2014 poverty level?
**As defined by HHS; check the HHS listing to answer this question: http://aspe.hhs.gov/poverty/14poverty.cfm
□ Yes □ No - Are you the first in your immediate family to attend college?
What is the primary language spoken at home? List all language spoken:___________________________________
______________________________________________________________________________________________
□ Yes □ No - Do you have a diagnosed disability or impairment?
If yes, please indicate: □ Hearing □ Visual □ Mobility □ Other: ________________________________________
□ Yes □ No - Have you served in the armed forces? If yes, indicate number of years served: _________________
□ Yes □ No - Do you identify as a career-changer?
If yes, what was your previous career: _______________________________________________________________
Last Name: First Name:
Street Address: City/State/Zip:
Gender: □ Male □ Female □ Decline to state
Email:
I am a: □ U.S. Citizen □ Permanent Resident □ Other:
Current C.C. Campus ID#:
Phone Number:
Cell phone:
Alternate Email:
How do you hear about us? □ Fliers/Posters □ Course Instructor □ Bridges Alumni □ Academic Advisor □ Website □ Class Visit
□ American Indian
□ Black or African American
□ Hispanic or Latino
□ White/Caucasian
□ Other: _______________________
□ Other: _______________________
□ Other: _______________________
Asian/Asian American
(select categories you identify with below)
□ Chinese
□ Vietnamese
□ Pakistani
□ Filipino
□ Cambodian
□ Thailander
□ Japanese
□ H’Mong
□ East Indian
□ Korean
□ Laotian
□ Bangladeshi
□ Indonesian
□ Other: _______________________
Pacific Islander
(select categories you identify with below)
□ Native Hawaiian
□ Guamanian
□ Samoan
□ Fijian
□ Polynesian
□ Tongan
□ Micronesian
□ Tahitian
□ Marshallese
□ Melanesian
□ Other: _______________________
Long Beach Bridges to the Baccalaureate (LB3) Program
California State University, Long Beach
Summer Undergraduate Research Opportunity for Long Beach City and Cerritos College Science Majors
LB3 Program: Application
Name: _______________________________________ Bridges Application - Page 2
Academic, Educational & Career Information:
Institutions Attended: (Please list all universities, colleges and community colleges; if more attach a separate page)
Completed Coursework: Please list all your completed math & science courses in the appropriate boxes below:
In-Progress Coursework: Please list your in-progress science courses in the appropriate boxes below:
Major:
Cumulative GPA:
Current Campus: □ Cerritos □ LBCC
Have you applied to transfer for Fall 2015? □ Yes □ No
If you have not applied to transfer for Fall 2015; when do you plan to apply for transfer?
□ Spring 2016
□ Fall 2017
□ Spring 2017
□ Fall 2018
What campuses have you applied or do you plan on applying to?
California State University (CSU):
□ CSU - Long Beach
□ CSU - Dominguez Hills
□ CSU - Fullerton
□ CSU - Northridge
□ CSU - Los Angeles
□ CSU - San Diego
□ CSU - San Marcos
□ CSU - San Jose
□ CSU: _______________________
University of California (UC):
□ UC - Los Angeles
□ UC - Berkeley
□ UC - Irvine
□ UC - Santa Barbara
□ UC - Riverside
□ UC - San Diego
□ UC - Davis
□ UC - Santa Cruz
□ UC - Merced
Other Private:
□ Stanford University
□ Claremont Colleges
□ Chapman University
□ Mt. St. Mary’s College
□ Western University
□ Other: ______________________
□ Other: ______________________
□ Other: ______________________
□ Other: ______________________
Institutions attending/attended
Degree/major program (e.g. Biology)
GPA
Course taken
Course Instructor
Semester Completed
Grade
Course In-progress
Course Instructor
Current Grade
Long Beach Bridges to the Baccalaureate (LB3) Program
California State University, Long Beach
Summer Undergraduate Research Opportunity for Long Beach City and Cerritos College Science Majors
LB3 Program: Application
Name: _______________________________________ Bridges Application - Page 3
Honors/ Awards:
Honors/ Awards:
** Please List additional Honors/Awards on a separate sheet of paper and attach to this application.**
Preferred Lab experience:
Please check the appropriate box(es) to indicate which lab experience you prefer (Select all that apply):
Field lab experience: experience involves being outdoors collecting the data/materials as well as working
inside the lab analyzing the data/materials collected.
Lab experience involving primarily computational and/or computer based experiments: this type of
experience involves a large amount of computer utilization and literature review.
Lab experience involving primarily biological/chemical experiments inside the lab and involves technical
work in a lab with specimens, liquids and reagents.
I have no preference and am comfortable in any research setting
References and Letters of Recommendation:
The Bridges Program requires two (2) separate letters of recommendation, using the attached Bridges
Recommendation Form. Complete the information below for each of your recommenders. (See attached for
detailed directions about the Recommendation Form.)
Name of Honor(s)/ Award(s)/ Recognition(s):
Awarding Entity:
Location of Awarding Entity:
Year Received or Initiated:
Name of Honor(s)/ Award(s)/ Recognition(s):
Awarding Entity:
Location of Awarding Entity:
Year Received or Initiated:
Name of Recommender #1:
Institution: □ Cerritos □ LBCC
Department:
Course Taken with this Instructor:
Semester Taken:
Phone:
Email:
Grade Received:
Name of Recommender #2:
Institution: □ Cerritos □ LBCC
Department:
Course Taken with this Instructor:
Semester Taken:
Phone:
Email:
Grade Received:
Long Beach Bridges to the Baccalaureate (LB3) Program
California State University, Long Beach
Summer Undergraduate Research Opportunity for Long Beach City and Cerritos College Science Majors
LB3 Program: Application
Name: _______________________________________ Bridges Application - Page 4
Disclosure Statement:
I understand that to track the progress and evaluate program effectiveness of the CSULB
Bridges to the Baccalaureate Program requires access to student information. The Bridges
to the Baccalaureate Program is required to report individual student data to the National
Institutes of Health including social security number, ethnicity, GPA, disabilities, and
enrollment status. Photographs and research abstracts may also be used by the Bridges to
the Baccalaureate Program in materials such as websites, brochures and reports.
I have read and understand all of the statements above. I hereby authorize release and use
of personal information for Bridges to the Baccalaureate Program, as described above. By
signing below, I understand that this information is to be used solely for evaluating the
impact and effectiveness of Bridges to the Baccalaureate Program and that individual
student data will not be released to parties other than those directly involved with the
program. I also understand that the Bridges to the Baccalaureate Program will require that
I respond to the annual alumni survey in a timely manner. By signing below I am
committed to provide the Bridges to the Baccalaureate Program annually with current
information in order to provide the program with the needed data to support future
students in this program.
Applicant’s Name (print, first & last): _______________________________________________
Applicant’s Signature: _______________________________________________ Date: ______________
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Bridges to the Baccalaureate
California State University, Long Beach
Summer Undergraduate Research Opportunity for Long Beach City and Cerritos College Science Majors
Bridges Recommendation Form
National Institutes of Health: Bridges to the Baccalaureate Summer Research Program
All application materials must be received by February 27
th
, 2015
Student Name: ________________________________ Student Signature: ________________________________
□ I waive my rights to view this recommendation and attachments.
□ I don’t waive my rights to view this recommendation and attachments.
*This recommendation must be submitted by the author directly to the faculty liaison listed in bold below.
Dear Evaluator,
In an effort to increase the number and quality of science students transferring to four-year universities the National Institutes
of Health and CSULB host the Long Beach Bridges to the Baccalaureate (LB3) Program for students from Cerritos and Long
Beach City College for a nine-week summer internship. We teach them laboratory skills, time management and help develop
their career goals.
The Bridges Committee depends on and appreciates your careful appraisal of the above named student’s potential. Your
judgment about this student’s potential in his/her desired major and career is critically important. Your recommendation
should include as much information as possible and remain confidential from the student. Please note any unusual
circumstances in the comments section of this form. A letter of support is optional; return all necessary documents to either
Mary Perrot (Office: D344) or Mehrzad Akhavan (Office: D249) at Long Beach City College or Matt Covill (Office: S-115) or
Linda Waldman (Office: S-213) at Cerritos College, by FRIDAY, February 27
th
, 2014. Please DO NOT return this form students.
Thank you for your time.
Evaluator’s Name: ___________________________________________ Department: _______________________
Email: ___________________________________ Phone: _______________________ Office: ________________
Student’s Observed Strengths: ____________________________________________________________________
______________________________________________________________________________________________
Student’s observed Weaknesses: __________________________________________________________________
______________________________________________________________________________________________
Comments—All information is confidential. Your comments about the applicant’s scholarship, leadership, attitude,
determination, ambition, financial need, etc., will be most helpful. Attach a separate sheet if necessary:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Evaluator Signature: ________________________________________________ Date: ______________________
RATING
Academic
Performance
Potential as a scientific
researcher
Attitude and commitment
to learning
Lab skills
Persistence in tasks not
immediately rewarded
OUTSTANDING
EXCELLENT
GOOD
FAIR
POOR (Explain)
No chance to
observe
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Bridges to the Baccalaureate
California State University, Long Beach
Summer Undergraduate Research Opportunity for Long Beach City and Cerritos College Science Majors
Bridges Recommendation Form
National Institutes of Health: Bridges to the Baccalaureate Summer Research Program
All application materials must be received by February 27
th
, 2015
Student Name: ________________________________ Student Signature: ________________________________
□ I waive my rights to view this recommendation and attachments.
□ I don’t waive my rights to view this recommendation and attachments.
*This recommendation must be submitted by the author directly to the faculty liaison listed in bold below.
Dear Evaluator,
In an effort to increase the number and quality of science students transferring to four-year universities the National Institutes
of Health and CSULB host the Long Beach Bridges to the Baccalaureate (LB3) Program for students from Cerritos and Long
Beach City College for a nine-week summer internship. We teach them laboratory skills, time management and help develop
their career goals.
The Bridges Committee depends on and appreciates your careful appraisal of the above named student’s potential. Your
judgment about this student’s potential in his/her desired major and career is critically important. Your recommendation
should include as much information as possible and remain confidential from the student. Please note any unusual
circumstances in the comments section of this form. A letter of support is optional; return all necessary documents to either
Mary Perrot (Office: D344) or Mehrzad Akhavan (Office: D249) at Long Beach City College or Matt Covill (Office: S-115) or
Linda Waldman (Office: S-213) at Cerritos College, by FRIDAY, February 27
th
, 2014. Please DO NOT return this form students.
Thank you for your time.
Evaluator’s Name: ___________________________________________ Department: _______________________
Email: ___________________________________ Phone: _______________________ Office: ________________
Student’s Observed Strengths: ____________________________________________________________________
______________________________________________________________________________________________
Student’s observed Weaknesses: __________________________________________________________________
______________________________________________________________________________________________
Comments—All information is confidential. Your comments about the applicant’s scholarship, leadership, attitude,
determination, ambition, financial need, etc., will be most helpful. Attach a separate sheet if necessary:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Evaluator Signature: ________________________________________________ Date: ______________________
RATING
Academic
Performance
Potential as a scientific
researcher
Attitude and commitment
to learning
Lab skills
Persistence in tasks not
immediately rewarded
OUTSTANDING
EXCELLENT
GOOD
FAIR
POOR (Explain)
No chance to
observe
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