Strong Children's Research Center

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.

After submitting or mailing your application, please call 585-275-8447 within 5 days 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 - May 27th - August 8, 2008

Haggerty-Friedman Psychosocial Fund (Medical Students)

First Name Middle Initial Last Name
   
Email Address (make sure this is a valid email address)
 
Present Address: 
Street City
State Zip Code
Home Phone Number  
 

Permanent Address and Phone Number (if different from above):
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

Sex: 
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 training program are you currently participating in?

Undergrad
MD
PhD
MPH
Other:

What training program would you consider pursuing in the future?

Undergrad
MD
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 2-4 names of potential SCRC mentors from the Investigator List (required). An "*" by a mentors name indicates that they are able to mentor during 2008.

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 weekly stipend of $300.00. Housing is provided for out of area students. The stipend will be paid in biweekly increments. Scholarships are not intended to provide financial support for required or elective courses.

Please send requested material (transcripts, letters of recommendation) to be received no later than March 1, 2008 to:

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

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 call 585-275-8447 within 5 days to verify your application was received.