Howard Hughes Medical Institute

(Please print or type.)

1. 1. Name__________________________________________

Last First Middle

2. 2. Mailing Address_________________________________

Number and Street

______________________________________________

City State Zip County

E-Mail Address _________________________________

Telephone Number (_)____________________

3. 3. Social Security Number ___________________________

4. 4. Gender (please circle): Male Female

5. 5. Date of Birth ____________________________________

Month Day Year

6. 6. Place of Birth ___________________________________

City State

7. 7. Citizenship _____________________________________

8. 8. How do you describe yourself? (Please circle one.)

Black (non-hispanic)

Hispanic (Mexican American / Puerto Rican / Cuban)

Native American

Asian American / Pacific Islander

White

Other

9. 9. High School ____________________________________

Number of years attended ___ Current Grade Level ____

10. 10. Name and address of parents or guardian

(circle applicable) father mother guardian

Name__________________________________________

Last First Middle

Address________________________________________

Number and Street

______________________________________________

City State Zip

Business Phone (_____)___________________________

11. 11. Father (circle) Living Deceased

Occupation _____________________________________

Educational Level _______________________________

Place of Birth ___________________________________

City State

12. 12. Mother (circle) Living Deceased

Occupation _____________________________________

Educational Level _______________________________

Place of Birth ___________________________________

City State

13. 13. Person who will know your location in two years

Name _________________________________________

Address________________________________________

Number and Street

______________________________________________

City State Zip

Telephone Number (_____)________________________

If you need more space, please use the back or attach a separate page.

14. 14. List any awards or honors you have received and/or significant activities in which you have been involved.

________________________________________________________________________________________________________

15. 15. Indicate what college/university you wish to attend, if known. In what subject do you intend to major (if known), or what are you interested in studying?

16. 16. Please indicate your reasons for wanting to participate in the Summer Intern Program. Include in your statement what you hope to gain from the program.

________________________________________________________________________________________________________

Signatures:

Student ___________________________________________________ Date __________________________

Parent or Guardian __________________________________________ Date __________________________

Attach copies of (1) your high school transcript; (2) your most recent report card, including first semester grades; and (3) ACT and/or SAT scores (or other standard testing if available).

Your completed Application Form must be submitted by May 31, 2007 to Dr. Mary McHale Dept of Chemistry—MS 60 Rice University Houston TX 77251-1892.

For additional information, call Dr. Mary McHale at (713) 348-5837.

Summer Academy, June 30 – July 11, 2008

(Please print or type.)

2. 2. Mailing Address_________________________________

Number and Street

______________________________________________

City State Zip County

E-Mail Address _________________________________

Telephone Number (_____)________________________

3. 3. Social Security Number ___________________________

4. 4. Gender (please circle): Male Female

Address________________________________________

Number and Street

______________________________________________

Address________________________________________

Number and Street

______________________________________________

Telephone Number (_)____________________