Pills, Potions and Poisons Student Application

Student Application

Personal Information

First Name

Last Name

Street Address

City

State

Zip Code

Birth Date

Race/Ethnicity

Where did you hear about the program?

Email Address

Gender

Do you have other potential engagements that you will be required to attend this summer? Do any of them conflict with any of the Pills, Potions and Poisons program dates/time?

Yes

Would you like to receive more information regarding our Bachelors of Science in Pharmaceutical Sciences and/or PharmD Programs?

Yes

Parent/Guardian Information

Parent/Guardian’s Name

Parent/Guardian’s Cell Phone

Parent/Guardian’s Email Address

School Information

Current School

Current Grade

GPA

on a scale of

*What high school science courses will you have completed by July 2023?

Biology 1

Biology 2 or AP

Chemistry 1

Chemistry 2 or AP

Other…

Have you previously applied to this program? (Check the appropriate box)

If 'Yes', please specify which year:

Teacher Nomination

Students applying to the Pills, Potions, and Poisons program must have a nomination from a high school science teacher. Please ask the teacher nominating you to complete the ‘Teacher Nomination Form’ found on our website.

Name of teacher nominating you:

Short Response

Find a recent news article (within the last year) that focuses on a science topic that interests you. Using the space below, write a brief essay (max. 250 words) summarizing the article and explain why you find it interesting. Please cite the source of your article.

Enter Short Response Essay

Signatures

Student Printed Name

Student Signature Date

Parent/Guardian Printed Name

Guardian Signature Date

Are you a human? 4 + 0 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.