Online Application

On-Line Applications and Supporting Materials must be received by February 22, 2008.
You will be notified of your acceptance no later than March 8, 2008.

 

Fields with an asterisk (*) are REQUIRED

I am a returning participant.
Applicant Type:
      
Other Team Members:
  Member #2:

Applicant Information
Professional title:* Academic title:
Administrative title: Clinical title:
First name:* Last:*
University/Institute:*
Office Street address:*
Office City:* Office
State:*		 Office
Zipcode:*
Home address:*    
Home City:* Home State:* Home Zipcode*:
Telephone (office):* Fax (office):*
Cell Phone:*    
Email:* Alternate
E-mail:		  
Degree(s) earned:

 Year(s) obtained:
Specific areas of interest*:
Are you interested in Continuing Education Credits?

 If "Yes", what kind?
Mailing address
(if different from above):

Emergency Contacts
Contact name*:
...Home phone*:
...Work phone*:
...Cell phone*:
Alternate Contact name*:
...Alt. Home phone:*
...Alt. Work phone*:
...Alt. Cell phone*:
Health Insurance Company*:
Policy Number*:
Any special medical or personal information you would want an emergency care provider to know?

Transportation / Needs / Restrictions
Travel method*: Flying    Driving
Other (Please specify: )
Special needs:
   (e.g., handicap accessibility, sign language interpreter, etc)
Dietary restrictions:
   (e.g., low-carb, vegetarian... please be very specific)
Religion/Worship service:
   (If not listed here [opens in new window] )
Faculty Only
Date of presentation:
Time of presentation:
A/V Needs:
I do NOT need any A/V equipment
Laptop Projector
Overhead Flip-Chart

W-9 Form: (Sue Diesel will inform you if you are required to complete this form)

Link to W-9 Form on IRS Site
(will open in another window)
  

Faculty Bio:

Please include your bio:
(approximately 225 words or 15 lines)


 

Registration Agreement
I understand that the CBPR Training Institute can accommodate only a limited number of applicants and that an applicant who fails to attend after acceptance denies another worthy applicant the opportunity to participate. Therefore, I assure the University of Rochester Office of Mental Health Promotion that, if accepted, I will participate in the full program of the 2008 CBPR Training Institute from the evening of April 26, 2008 through the morning of May 1, 2008.

I have read and understand the above statement*

 
Name*: Date*:

After submitting this application, you will be asked to attach the supporting materials listed at the right in a separate email to:



Sue Diesel
sue_diesel@urmc.rochester.edu
University of Rochester Medical Center
300 Crittenden Blvd., Box PSYCH
Rochester, NY 14642
585-275-3571 (phone)
585-275-6666 (fax)

 

Supporting Materials Checklist

  • At least one letter of support for each team member written by a director, dean or department chair.

  • A jointly-authored three-page statement of collabortative research intent in concept paper form that includes:

    • a) the names of partners, basis of their interest in the training, how the training experience will advance the research goals of the partnership, and what is innovative about their proposed effort (one page).


    b) Research aims, research focus, study design, information about the study population, expertise of the research team, location, and expected public health and policy relevance (two pages).
  • Up-to-date Curriculum Vitae for each team member.