Strong Children's Research Center

2010 Summer Training Program

To apply, please fill out and submit this form by clicking the "submit" button at the end of this application or print the form and mail it in. Aplications will be accepted from 11/23/2009 - 3/1/2010.

After submitting or mailing your application, wait 3 business days and then please email Dawn L. Smith (dawnL_smith@urmc.rochester.edu) or call 585-275-8447 to verify your application was received.

General Information

Please check the appropriate box (NOTE: Students applying for the Haggerty-Friedman Summer Program should check both boxes):

Summer Program Application - June 1 - August 6, 2010.

Haggerty-Friedman Psychosocial Fund (Medical Students)

If your medical school year ends after June 1, but you are able to do 10 weeks of research during the SCRC Summer Program, please contact Dawn Smith. (see contact information above)

First Name Middle Initial Last Name
   
Email Address (Please list email below)
 
Email Address (Please confirm email address)
 
Present Address:
Street City
State Zip Code
Best Telephone Number to Reach You  
 

Permanent and/or Parental Address
Street City
State Zip Code
Phone Number
Date of Birth
U.S. Citizen: Permanent Visa Status (if not U.S. citizen):
Yes


No 		Yes


No

The information requested below is strictly voluntary

Gender:

Male

 

Female
Ethnicity:

African American

Asian

Caucasian

Hispanic

Native American

Other

Education Record

Undergraduate Institution:
 
Address Dates Attended
Date of Graduation Degrees or Diplomas

Medical School: (Currently Attending) Include Date Accepted and Matriculation

Please answer the following questions.

How did you learn about the SCRC Summer Program?
Internet
Website
Professor/ Teacher
Career Center at school
Other
Why do you wish to participate in this program?

If you have participated in research-related activities, please describe them.

What are your scientific research interests?

What are your career goals?

What is your current level of education?

Undergrad student
MD student
Graduate student
Other:

What training programs are you planning to pursue?

MD
MD, PhD
PhD
MPH
Other:

Have you participated in the SCRC Program before?

Yes
No

If yes, would you like to return to the lab or clinical setting you were in before?

Yes
No

If you are an undergraduate, have you applied or been accepted into medical school?
If accepted to medical school, give the name of the school and the planned date of matriculation.

Medical School Name Planned Date of Matriculation

If I am awarded a Research Fellowship, I agree to participate in the weekly seminar program and provide an abstract and a poster at the completion of my research program. Typing your full name in the text box below serves as evidence of your agreement to these terms.
Applicant Signature

List 4-8 areas of research that interest you (i.e. General Pediatrics, Nephrology, Hematology/Oncology, Developmental Disabilities, Pulmonary, Infectious Disease, Neuroscience) Also in this same box please state the type of reseach you are interested in: basic/bench, clinical research, or health services.

 

 

References

Please list the names and addresses or telephone numbers of at least 2 faculty members you have asked to write letters of recommendation on your behalf.
Reference #1   Work Phone
Street City
State Zip Code
Relationship  
 
Reference #2   Work Phone
Street City
State Zip Code
Relationship  
 

Note:

Please have an official transcript sent from your college or Medical School. Trainees will receive a monthly stipend of $1500.00 for the months of June and July. The stipend is paid in monthly increments in June and July. Housing is provided for out of area students. Scholarships are not intended to provide financial support for required or elective courses.

 

Please send all requested material (transcripts, letters of recommendation) to be received no later than March 1, 2010 to:

Dawn L. Smith
Strong Children's Research Center
URMC, Department of Pediatrics
601 Elmwood Avenue, Box 777
Rochester, NY 14642
FAX (585) 271-7512
dawnl_smith@urmc.rochester.edu

 

If all requested materials are not received by 3/1/10 your application will not be considered for the program.

Please make sure you have filled out all parts of this application to your satisfaction before submitting it. This application cannot be processed if the first name, last name, and email address required fields are not filled in. The email address you provide must be a valid email address or this application will not be processed. It is possible that you could lose all the information you have already entered if these three fields are not filled in correctly.

After submitting your application, please email or call 3 business days after submitting the application to verify your application was received.