2021 Application

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CIQM Summer School: 2021 Application Form

* Indicates required field

Name *

First

Last

Email *

How did you hear about the CIQM Summer School? Please list all ways that apply, and include name of who recommended CIQM if possible. *

Summer School Project Interests:

Describe your Research Interests *

CIQM Online Course Offerings, Click all that Apply *

An Introduction to Linear Algebra Using Python, Steven Richardson, May 18 - August 9, Tuesdays 2:00pm -3:35pm - optional one-hour recitation to follow Brookhaven National Lab (BNL) Foundations in Quantum Programming, June 14 - July 9, M-F 8:30am - 4:30pm American Sign Language Classes

Please check all that apply

Demographics

Will you be over 18 by May 16, 2021 *

Yes No

Gender *

Male Female Other

Race *

White Black Asian Native American Pacific Islander Mixed

Ethnicity *

Hispanic Non-Hispanic

Family History (optional): What is the highest level of education obtained by your parent(s) or legal guardian(s)? *

Citizenship Category *

United States Permanent Resident Non US Attending University

Citizenship Country *

Are you a Dual Citizen? *

Yes No

Disability (optional) *

Yes No

If yes, what is your disability? *

Military Background (optional): Are you a Veteran or an active member of the United States Military (including reserves)? *

Yes No

Education History

Current Institution *

Enroll Date: *

Approximate Graduation Date: *

What is your last exam date for the spring semester? *

Have you attended any other institutions? *

If so, please list name of Prior Institution 1: *

Date Attended From: *

Date Attended To: *

GPA *

Prior Institution 2 *

Date Attended From: *

Date Attended To: *

GPA *

What Year are You? *

Major *

GPA *

What is the highest level of degree awarded in Science/Engineering at your school? *

High School Name: *

City, State: *

Date Attended From: *

Date Attended To: *

GPA *

Scholarships, Honors, and Awards

Please list briefly any significant scholarships, honors, or awards you have received․ *

Skills

Please list briefly any skills relevant to research such as computer languages or machine shop experience․ *

Research and Work Experience

Do you have prior Research experience? *

Yes No

Do you have prior Work (or Military) experience? *

Yes No

Work Experience Details

Prior Employment #1

Employer *

Date Employment From: *

Date of Employment To: *

Supervisor(s): *

Description: *

Prior Employment #2

Employer *

Date of Employment From: *

Date Employment To: *

Supervisor (s): *

Description: *

Resume/CV (Optional) *

Max file size: 20MB

please upload your Resume/CV as a pdf

Contact Information

Phone Number *

Permanent Address

Street *

Apt or Unit *

City *

State or Province *

Zip Code *

Country *

Is your permanent address the same as your mailing address? *

Yes No

Research Statements

Research Statement: *

Personal Statement

Personal Statement: *

Transcript

Upload Your Transcript *

Max file size: 20MB

Recommendations

Upload a File with your Letter(s) of Recommendation *

Max file size: 20MB

Submit

PI: Robert
Westervelt

Co-PI
Tina Brower-Thomas,
Kim Jones

Co-PI
Raymond Ashoori

Co-PI
David Sittenfeld

Supported by a grant from the National Science Foundation