Charles R. Drew Saturday Academy 2014

Application Letter August 26, 2013 Dear Applicant: Cleveland Clinic is pleased to inform you that applications are now being accepted for the Charles R. Drew Saturday Academy Program. Deadline to apply is Friday, October 4, 2013. The Charles R. Drew Saturday Academy is a collaborative internship program sponsored by Cleveland Clinic and Health Legacy of Cleveland, Inc. This enrichment program is designed for underrepresented minority (American Indian, Black/African American, Hispanic/Latino, and Native Hawaiian/Pacific Islander) 10 th through 12 th grade high school students with a health care career goal of becoming a physician, research scientist, physician investigator, physician leader, general dentist or dental specialist. Saturday Academy focuses on providing participants with career information and critical skill sets to support their matriculation through higher education, medical and dental school, and beyond. Students engage with health care professionals to learn of the various aspects associated with the fields of medicine, science, and dentistry. Talks; tours; a one-on-one mentoring session with a healthcare professional; hands-on activities; and the implementation of a community blood drive are all part of this intensive program. A monetary stipend will be awarded upon successful completion of the program. Applicants selected as finalists for participation in the Saturday Academy Program must commit to attend all of the following sessions (Note: with the exception of field trips and/or other scheduled activities, the majority of the Saturday Academy sessions will take place at Cleveland Clinic s Main Campus location): Orientation/Kick-Off: Saturday, January 11, 2014 from 8:30 a.m. to 2:30 p.m. A parent/guardian is required to attend during the same hours on this date; Regular Saturday Sessions: Eleven (11) additional consecutive Saturday sessions from Saturday, January 18, 2014 through Saturday, March 29, 2014. Regular Saturday sessions will run from 8:30 a.m. to 3:30 p.m.; Recognition Ceremony: Wednesday evening, April 2, 2014 from 5:30 p.m. to 7:30 p.m. All participants and parents/guardians are required to attend. Please encourage your child(ren) to apply for this valuable educational opportunity! All application forms and required documents must be completed and submitted as outlined on the enclosed Application Checklist on or before 5:00 p.m., Friday, October 4, 2013 to: By US Mail to: Angie Eichelberger Program Manager Office of Diversity and Inclusion Cleveland Clinic 9500 Euclid Avenue, UA20 Cleveland, OH 44195 By E-mail to: diversity4u@ccf.org Applications that are incomplete, missing documentation, and/or received after the deadline of Friday, October 4, 2013 will not be considered. Please contact Jackie Tinsley, Program Assistant at (216) 445-7361 or by e-mail to diversity4u@ccf.org with questions. Best Regards, Angie Eichelberger Enclosures 1

Eligibility Criteria APPLICATION DEADLINE IS 5:00 p.m., Friday, October 4, 2013 Student Must: Have a strong interest and aptitude in science and math; Be an Underrepresented Minority in Medicine (URMM) American Indian, Black/African American, Hispanic/Latino, and Native Hawaiian/Pacific Islander; Be 15 years of age by January 1, 2014; Currently be in the 10 th, 11 th, or 12 th grade (during the 2013/2014 academic year); Have a cumulative GPA of 3.5 or better on a 4.0 scale (as demonstrated by an official transcript); Submit the Application and Supporting Documents, Essay, and Reference Letters. Please refer to the Essay Guidelines and Questions form included in this packet for instructions on how the essay must be formatted; Submit Written Documentation of Good Health (this includes): Complete Certified Immunization Record showing that the student has been immunized against the common communicable diseases; You must refer to the Application Checklist included in this packet for all required documentation to be submitted with your application; Note: acceptance into the Cleveland Clinic Charles R. Drew Saturday Academy Program is also contingent upon the selected students completion and passing of Cleveland Clinic s pre-employment physical exam including a test for TB, a drug screen and a Cotinine testing for tobacco use, receipt of the H1N1 Combined Flu Vaccination, and completion of the COMET On-line Training Modules to occur in November 2013; Attendance at each session is mandatory for selected participants; Final selections will be made by Cleveland Clinic and Health Legacy of Cleveland, Inc. and will be based upon the strength of the student s GPA, written essay, and letters of reference. Cleveland Clinic / Health Legacy of Cleveland Inc. reserves the right to reject any applicant. The decisions of Cleveland Clinic / Health Legacy of Cleveland Inc. are final and not subject to review. Students will be notified via e-mail or letter via US mail in October regarding the status of their application. Parent/Guardian Must: Review and sign all consent forms; and complete and sign the parent/guardian Letter of Reference; Commit to supporting selected student s attendance at each session; Attend the Orientation Kick-off and Recognition Ceremony with selected student. Instructions for Submitting Completed Applications ALL application materials and supporting documents must be received by 5:00 p.m. on Friday, October 4, 2013. Partial applications or those e-mailed, hand delivered or received in the mail after the deadline will not be accepted -- NO EXCEPTIONS! By US Mail to: Angie Eichelberger Program Manager Office of Diversity and Inclusion Cleveland Clinic 9500 Euclid Avenue, UA20 Cleveland, OH 44195 By E-mail to: diversity4u@ccf.org The preferred method of delivery is by US mail or E-mail, to be received on or before the date above. However, should you need to arrange to drop off your application in-person (by the deadline date of October 4, 2013), you must contact Jackie Tinsley in advance at (216) 445-7361 for approval and to obtain detailed instructions for delivery (the address above is for mailing purposes only). Faxes will not be accepted. 2

Application Checklist & Signature Page Student s Name: Please attach the requested information below in the following order: 1: Application Checklist and Signature Page (this page) 2: Student Application Form 3: 500-word double-spaced typed essay. Please be sure to follow the format outlined on the Essay Guidelines sheet included in this application packet. 4: Parent/Guardian Authorization Form (all pages) 5: Parent/Guardian Letter of Reference 6: Guidance Counselor Letter of Reference 7: Teacher (Science or Math) Letter of Reference 8: Official High School Transcript 9: Copy of Student s Official State of Ohio ID, Driver s License or Temporary Driver s Permit 10: Copy of Student s Social Security Card 11: Complete Certified Immunization Record showing that the student has been immunized against the common communicable diseases 12: Signatures on all application forms and below (required): I verify that this application was completed in its entirety by me: Student s Signature: Date: I support my child in his/her participation in the Charles R. Drew Saturday Academy Program: Parent/Guardian s Signature: Date: I have reviewed the complete application for this student: Guidance Counselor s Signature: Date: ALL application materials and supporting documents must be received by 5:00 p.m. on Friday, October 4, 2013. Partial applications or those e-mailed, hand delivered or received in the mail after the deadline will not be accepted -- NO EXCEPTIONS! By US Mail to: Angie Eichelberger Program Manager Office of Diversity and Inclusion Cleveland Clinic 9500 Euclid Avenue, UA20 Cleveland, OH 44195 By E-mail to: diversity4u@ccf.org The preferred method of delivery is by US mail or E-mail, to be received on or before the date above. However, should you need to arrange to drop off your application in-person (by the deadline date of October 4, 2013), you must contact Jackie Tinsley in advance at (216) 445-7361 for approval and to obtain detailed instructions for delivery (the address above is for mailing purposes only). Faxes will not be accepted. 3

Student Application Form Charles R. Drew Saturday Academy 2014 The 2014 Charles R. Drew Saturday Academy Program starts on Saturday, January 11, 2014 (orientation/kickoff); runs for Eleven (11) additional consecutive Saturday sessions from Saturday, January 18, 2014 through Saturday, March 29, 2014, and ends on Wednesday, April 2, 2014 (recognition ceremony). APPLICATION DEADLINE IS 5:00PM, FRIDAY, OCTOBER 4, 2013 o o Use a black ink or ballpoint pen to complete your form. DO NOT USE PENCIL. Make sure you sign and date forms requiring a signature in ink. Student Last Name Student First Name Middle Initial Social Security # Date of Birth (mm/dd/yyyy) Current Age Gender (circle one): Female Race/Ethnicity (Optional) American Indian Black/African American Hispanic/Latino Native Hawaiian/Pacific Islander Other Address Male City/State/Zip County Home Phone Number ( ) Cell ( ) Home/Personal E-Mail Emergency Contact Name Emergency Contact Daytime Phone Number Relationship to You School Name School District School Address School City/State/Zip School County 2013-2014 Grade Level Anticipated HS Graduation Date College/University of Choice Career Interest Have you participated in other Cleveland Clinic-sponsored programs? Yes If you answered yes, please list the program(s) here: No By signing below, I certify that the information contained in this form is accurate and complete. Student s Signature Date 4

Essay Guidelines & Questions As a part of the application for the Charles R. Drew Saturday Academy Program, all applicants are required to submit an essay with their application packet to be considered for participation in the program. Please answer the following statements to the best of your ability. Take time to think about and formulate your answers. Make sure your answers are concise, but thorough. The essay should be formatted as follows: 500-words, typed in Arial 10 point font (hand-written essays will not be accepted) double-spaced 1 st Paragraph Provide an introduction to include: your first name, middle initial and last name the name of your high school current grade include participation (if any) in other Cleveland Clinic programs to include the program name(s) and the year(s) of participation For the following, please answer each question in a separate paragraph and include the question number and the question itself in your answer: 2 nd Paragraph, Question 1: I am interested in being selected as a Charles R. Drew Saturday Academy participant because: 3 rd Paragraph, Question 2: Please share your desired career (i.e. pediatrician, genomics researcher, or endodontist) and the reason you are interested in becoming this specific type of physician, research scientist, or dentist. 4 th Paragraph, Question 3: What character traits, skills and abilities do you possess that would make you well-suited to a career in medicine, science or dentistry? 5 th Paragraph, Question 4: Would you return to the Greater Cleveland area, and perhaps Cleveland Clinic, to practice a health care career? Why? 5

Parent/Guardian Authorization Form Charles R. Drew Saturday Academy 2014 The 2014 Charles R. Drew Saturday Academy Program starts on Saturday, January 11, 2014 (orientation/kickoff); runs for Eleven (11) additional consecutive Saturday sessions from Saturday, January 18, 2014 through Saturday, March 29, 2014, and ends on Wednesday, April 2, 2014 (recognition ceremony). APPLICATION DEADLINE IS 5:00PM, FRIDAY, OCTOBER 4, 2013 o o Use a black ink or ballpoint pen to complete your form. DO NOT USE PENCIL. Make sure you sign and date forms requiring a signature in ink. Student Name Parent/Guardian Contact Information Parent/Guardian Name Address City/State/Zip Home Phone Number ( ) Cell ( ) Daytime Phone Number ( ) E-Mail (daytime) (home) Work Phone ( ) FAX ( ) Parent/Guardian Medical Consent Part I: I hereby authorize the Cleveland Clinic and its physicians, nurses, and employees to provide or seek medical services and treatment to/for (print minor's name on line), a minor, my child (biological or legal through adoption or guardianship), should such medical services and treatment become necessary while said minor is either at any facility of the Cleveland Clinic, or in the company of a clinic employee acting as my child s mentor, advisor, preceptor, chaperone or other role as part of the Charles R. Drew Saturday Academy Program. Part II: To the best of my ability and current knowledge, my child s existing allergies, if any, are (if none, please print none) Part III: To the best of my ability and current knowledge, medications currently being taken by my child are (if none, please print none) Part IV: My health insurer is Policy # Primary Physician s Name Their telephone number is 6

Parent/Guardian Signature of Agreement for Participation, (print minor's name) is authorized by the undersigned to participate in all activities related to the Cleveland Clinic Charles R. Drew Saturday Academy Program. These activities may include, but not be limited to, research assignments, tours, field trips, special sponsored events, shadowing experiences, onsite procedural and laboratory participation & observations, observation of medical procedures, access to and interaction with patients being treated by health professionals, observation, handling of and potential exposure to laboratory testing equipment and materials (such exposure may include bodily fluids such as blood, and microorganisms such as bacteria and fungi);observation and potential exposure to bioengineering equipment, electrical charges, and lasers and mentoring activities, performance of tasks and participation in hands-on experiences permitted through on-site training by a Cleveland Clinic employee. (The above are examples of the types of activities the students may participate in or observe during his/her participation in the program. It is not intended to be a complete or binding list of all program activities.) These activities will take place at the Cleveland Clinic facility your child is assigned to as well as on our Main Campus located at 9500 Euclid Avenue, Cleveland, OH, and other Cleveland Clinic and external facilities that may be identified suitable for specific activities. In consideration of the above named minor s participation in these activities, the undersigned, as the parent or legal guardian of the above named minor, releases and discharges the Cleveland Clinic, the Office of Diversity and Inclusion, your home School District, your home School Board, your home School, and individual volunteers therein, as well as their respective officers, directors, board members, employees, agents and representatives, from all liability arising out of or related to the program and participation in the program by my child. Further, it is understood that the education partnership relationship that your home School, School Board and School District has with Cleveland Clinic does not include health care services, nor does it affect individual health insurance obligations, even if the need for emergency care or medical treatment should occur. The undersigned further authorizes the Charles R. Drew Saturday Academy Program, the Office of Diversity and Inclusion, Cleveland Clinic, their agents or employees, any of its physicians, or other persons, including members of the external media, print and/or broadcast, authorized by Cleveland Clinic, the Charles R. Drew Saturday Academy Program and/or the Office of Diversity and Inclusion, to interview my child or photograph, make motion sound pictures, movies, videotapes, or audiotapes, of my child. I agree that the interview, negatives, prints, videotapes, audiotapes, or computer graphics prepared therefrom may be used for any purpose, including: medical research, grant writing, professional or patient education, newspapers, magazines, web sites, Intranet, Internet, television, billboards, displays, exhibits, audiovisual or multimedia presentations, kiosk imaging, radio broadcasts, and any other news, public service, promotional, or advertisement reason, especially to further the aims and objectives of this program. I acknowledge that such use may occur at unspecified times after the date of this Authorization, whether my child is alive or not. I acknowledge that any photograph, motion sound picture, movies, videotape, or audiotape taken of my child will become and remain the sole property of Cleveland Clinic or of the authorized print or broadcast media organization. Further, as this program is designed to provide a meaningful and practical educational experience for the student, I understand and approve of my son s/daughter s/minor dependent s possible participation in activities such as those described in this application. I understand that Cleveland Clinic will exercise reasonable care in the supervision of the student and the determination of his/her actual assignments during their participation in the program. Students will be provided with protective garments, personal monitoring devices and/or other safeguards (including testing if necessary) as normally provided Cleveland Clinic employees present in such areas. By signing below, I agree that I have read and understand this agreement and that I will support his/her participation by doing the following: Promptly signing and returning any forms requiring my signature; Stressing appropriate dress/behavior for CC placements; Adherence to CC policies; Explaining the importance of teamwork and participation on their placement and encouraging my son/daughter/minor dependent to ask questions, and participate during their CC placement; Abiding by all Charles R. Drew Saturday Academy Program policies and procedures; Student Signature of Agreement for Participation I acknowledge that I have been provided with adequate information about the purpose and content of the Cleveland Clinic Charles R. Drew Saturday Academy Program and my responsibilities related to successful participation in the 7

program. I have reviewed the terms provided herein and in consideration of my participation in the program and the Partnership, and by signing below, indicate understanding of and agreement to these terms. I certify that the information contained in this document is true and complete, and understand that falsification and/or misrepresentation of this information is grounds for refusal or dismissal from the program. Parent/Guardian & Student Vacation or Time Away Scheduling Agreement I understand that the opportunity offered to me/my child through this program is an intensive, eleven (11) week program, on consecutive Saturdays (orientation will also occur on a Saturday and the recognition ceremony will take place on a weekday as announced). In order to achieve the specific objectives of the program and allow for successful completion of the student activities, there is no allowance for vacation or time off during the duration of the program (Cleveland Clinic and its employees have the right to make exceptions only under extenuating circumstances and at the sole discretion of the program manager and program facilitator). I/your child will be expected to be present at my/their designated meeting and/or activity location each day of the eleven (11) weeks. To that end, I agree to not schedule any other activities or appointments, academic, personal or otherwise, that may conflict with my/their placement. I certify that the information contained in this document is true and complete, and understand that falsification and/or misrepresentation of this information is grounds for refusal or dismissal from the program. Signature of Parent/Guardian Date Signature of Student Date Make sure you sign and date the form using a black ink or ballpoint pen. 8

Please Print Charles R. Drew Saturday Academy 2014 Parent/Guardian Letter of Reference Student s Name: Grade Level: GPA: School Name: The aforementioned student is applying for acceptance into the Charles R. Drew Saturday Academy Program. We would appreciate your candid responses and remarks about this student, including your DETAILED assessment of the following: 1. Leadership Potential: 2. Responsibility: 3. Interest in and Aptitude for Science and Math: 4. Attitude Towards School/Homework: 5. Level of Maturity: 6. Interaction with Peers and Others: 7. Additional comments are required: Parent/Guardian s Name: Relationship to Applicant: Address: City, State and Zip Code: Phone: ( ) E-mail: To Be Signed by the Parent/Legal Guardian: I understand that my child has made application to the Charles R. Drew Saturday Academy Program. If my child is selected, I understand that he/she will participate at no costs to me. However, I do understand that it is my responsibility to transport my child to and from the scheduled sessions and to ensure that he/she will be on time. I also understand that any misrepresentations made by me or my child may be cause for rejection of the application and/or removal from participation in the program. My signature below also acts as authorization for each high school that my child has attended to release academic information to Cleveland Clinic (or its representative). Parent/Guardian s Signature: Date: 9

Guidance Counselor Letter of Reference Please Print Student s Name: Grade Level: GPA: School Name: The aforementioned student is applying for acceptance into the Charles R. Drew Saturday Academy Program. We would appreciate your candid responses and remarks about this student, including your assessment of the following: 1. In what capacity and for how long have you known the student? 3. Aptitude for Science & Math (please check one): Top 10% Top 25% Top 50% 5. Leadership Potential: 2. Is the student enrolled in a college prep curriculum? Yes No 4. Level of Maturity (please check one): Above Average Average Below Average 6. Responsibility: 7. Interaction with Peers and Others: 8. Do you have any specific knowledge from the student about his/her career aspirations? In what field or fields do you feel they could be successful? 9. Would you recommend this student? Yes No 10. Additional comments are required: Guidance Counselor s Name: High School: Address: City, State and Zip Code: Phone: ( ) E-mail: Guidance Counselor s Signature: Date: 10

Teacher (Science or Math) Letter of Reference Please Print Student s Name: Grade Level: GPA: School Name: The aforementioned student is applying for acceptance into the Charles R. Drew Saturday Academy Program. We would appreciate your candid responses and remarks about this student, including your assessment of the following: 1. In what capacity and for how long have you known the student? 3. Aptitude for Science or Math (please check one): Top 10% Top 25% Top 50% 5. Student s Response to Teacher/Lessons: Listens and follows directions Volunteers to help Works well under pressure Work is always completed in a neat / orderly fashion Analyzes the nature of a problem before starting to solve it Gives good suggestions for solving problems 7. Interaction with Peers and Others: Cooperates with other students and teachers Joins clubs and organizations Attends after-school activities Outgoing and sociable 2. Is the student enrolled in a college prep curriculum? Yes No 4. Level of Maturity (please check one): Above Average Average Below Average 6. Attitude Towards School/Homework: Works hard, even in courses he/she does not like Good study habits Well organized and prepared/good time management skills Reads assigned chapters/completes homework Motivated and determined 8. Would you recommend this student? 9. Do you have any specific knowledge from the student about his/her career aspirations? In what field or fields do you feel they could be successful? 10. Additional comments are required: Yes No Teacher s Name: Position/Title: High School: Address: City, State and Zip Code: Phone: ( ) E-mail: Teacher s Signature: Date: 11