A Guide to the Art Collection - Roswell Park Comprehensive ...
On-line application: 2014 Roswell Park/Howard University ... · On-line application: 2014 Roswell...
Transcript of On-line application: 2014 Roswell Park/Howard University ... · On-line application: 2014 Roswell...
On-line application: 2014 Roswell Park/Howard University Cancer
Scholars Program
A. Background Information
*1. Are you a current Howard University Honors Biology Sophomore applying to the
"Howard/Roswell Park Cancer Scholars Program?"(*Required)
Select one. Yes
No (Answer question number 1.1.)
**Program Ineligibility**
Only Honors Sophomores are eligible to apply to the Roswell Park/Howard University Cancer Scholars Program. However, if you are junior, you may be eligible to apply to the Roswell Park Cancer Institute "Summer Research Experiences in Cancer Science" Program. (www.roswellpark.edu/summer-programs) Please exit from the application.
2. Provide your legal name as it appears on government-issued documents. If you do not
have a middle name, enter"none."
*First name:
*Last name:
*Middle name:
*3. Date of birth (RPCI policy prohibits anyone under the age of 14 to participate in
laboratory research)(*Required)
Enter a date on or before June 19, 1998.
4. Gender
Select one. Male
Female
*5. Citizenship(*Required)
Select one. U.S. Citizen
Permanent Resident (Answer question number 5.1.)
Foreign (Answer question number 5.2.)
*5.1 IF YOU SELECTED "Permanent Resident" IN QUESTION 3, please indicate place
of permanent residency:(*Required)
Select one. United States
Commonwealth of Puerto Rico
Northern Mariana Islands
Guam
American Samoa
Trust Territory of the Pacific
**Only "U.S. Citizens" or "Permanent Residents" are eligible to apply to the program.**
We're sorry, the eligibility requirements of targeted funding sources precludes foreign students from applying to the Roswell Park/Howard University Cancer Scholars Program. Please exit the application.
6. Are you the first generation in your family to attend college? (Optional)
Select one. Yes
No
7. Is anyone in your immediate family in a scientific or health-related profession?
(Optional)
Select one. Yes
No
*8. Temporary/school email address:(*Required)
*9. Permanent/personal email address:(*Required)
*11. Permanent/Personal cell phone number:(*Required)
12. Temporary/on-campus mailing address:
*Number and Street:
*City:
*State: Select one. Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
American Samoa
Guam
U.S. Virgin Islands
Other
*Zip Code:
13. Permanent/home address (parent or guardian address):
*House Number and Street:
*City:
*State: Select one. Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
American Samoa
Guam
U.S. Virgin Islands
OTHER
*Zip Code:
*14. If you are accepted into the program, will you require dormitory housing.
(Commuting distance must be greater than 2 hrs roundtrip by car)?(*Required)
Select one. Yes
No
B. Eligibility for targeted funding sources
Funding sources may be available that target certain populations of applicants based on being an under-represented minority or economically disadvantaged. If you believe you qualify in one or both of these categories, answer the questions in this section to apply to these funding sources. IT IS IMPORTANT TO NOTE: Acceptance into this program and the award of a stipend is based on the merits of your application. The potential source of your stipend funding is based on how you answer the questions in this section.
15. Demographic background
Select one. African American
American Indian or Alaskan Native
Pacific Islander (including Fijian, Hawaiian, Samoan)
Latino (including Mexican American; not Puerto Rican)
Puerto Rican
White, Anglo, Caucasian American (non-Hispanic)
16. Check any of the following financial aid programs for which you are eligible. This
information can be found on the "Student Aid Report (SAR)" that is created from
applying for federal student aid using the FAFSA form.
Select all that apply. Academic Competitive Grant
Federal Supplemental Educational Opportunity Grant
Federal Pell Grant
Low-income household
Scholarships for Disadvantaged Students
C. Academic Background
*17. Confirm your current enrollment status(*Required)
Select one. College/University
18. Provide the information about your current school below.
*Name of college or university: Select one. Howard University (DC)
Campus (if applicable):
*City:
*State: Select one. Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
American Samoa
Guam
U.S. Virgin Islands
Other
*Zip code:
*19. Anticipated/graduation date:(*Required)
*20. Degree sought/earned(*Required)
Select one. BA
BS
Other
*21. What scale is used to determine your grade point average (GPA)?(*Required)
Select one. 4.0 GPA
3.0 GPA
100%
Other:
22. Provide your GPA (include the most recently completed semester):
*Cumulative GPA:
*Science GPA:
*23. Select courses or course equivalents you have taken so far including those you will
take/are taking in the current spring semester.(*Required)
Select all that apply. Biology I
Biology II
Biology III
Chemistry I
Chemistry II
Organic Chemistry I
Organic Chemistry II
Physics I
Physics II
Genetics
Molecular Biology
Cellular Biology
Biochemistry
Immunology
Microbiology
Statistics
Computer Science
*24. Does your school rank students based on overall GPA?(*Required)
Select one. Yes (Answer question number 24.1.)
No
24.1 Provide your class rank. Use only the numerical ranking, for instance a "1" instead
"1st" or "first." If indicating a percentile rank, use only the integer. For instance, "10" for
top ten percentile.
*Your class rank:
*Is this a number rank or percentile?:
*Number of students in your class:
25. Provide scores for any standardized tests you have taken:
Verbal GRE:
Quantitative GRE:
Verbal MCAT/DAT:
Life Science MCAT/DAT:
Physical Science MCAT/DAT:
26. Discipline of study
*Major:
Minor:
Special Program (i.e. Honors):
27. For any science/health-related co-curricular activities in which you participate(d), list
achievements, memberships and leadership positions. For multiple items in a field(i.e.
more than one award) name each in most recent chronological order and separate by a
comma. If none, type "None."
*Awards and achievements:
*Society and club memberships:
*Officer/leadership positions:
28. If applicable, check any of the following academic programs in which you are
enrolled:
Select all that apply. Louis Stokes Alliance for Minority Participation
(LSAMP) (Answer question number 28.1, 28.2.)
Minority Access to Research Careers (MARC) (Answer question number 28.1, 28.2.)
Minority Biomedical Research Support (MBRS) (Answer question number 28.1, 28.2.)
McNAIR (Answer question number 28.1, 28.2.)
Other:
(Answer question number 28.1, 28.2.)
*28.1 Does your program provide a stipend for externships?(*Required)
Select one. Yes
No
28.2 Provide information about your specialized academic program below:
*Name of sponsoring institution:
*Name of program coordinator:
*Email contact for program Coordinator:
*Phone contact for program Coordinator:
*Allotted stipend amount:
*Duration of time funded by stipend (in weeks):
*URL to program website:
D. Previous Research Experience(s)
*29. Are laboratory research facilities and mentorship readily available at your school or
college?(*Required)
Select one. Yes
No
*30. Have you participated previously in research internships or have prior research
experience?(*Required)
Select one. Yes (Answer question number 30.1, 30.2.)
No
*30.1 Indicate the type(s) of research experience(s) in which you participated?(*Required)
Select all that apply. Intramural College Honors/Thesis Research
Extramural College Internship
Roswell Park Summer Research Program- High School
Informal internship at Roswell Park Cancer Institute
30.2 Provide the information below about your MOST RECENT research experience.
*Institution/university site of internship:
*City:
*State: Select one. Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
American Samoa
Guam
U.S. Virgin Islands
OTHER
*Zip code:
*Project topic:
*Name of research supervisor:
*Department:
*31. Have you given scientific talks or presentations?(*Required)
Select one. Yes (Answer question number 31.1, 31.2.)
No
*31.1 What type of talk/presentation did you give?(*Required)
Select all that apply. College seminar
Invited college conference
Invited scientific conference
31.2 Provide the following information about your most recent scientific talk:
*Topic/Title:
*Name of Institution Site:
*Year:
E. Education and Career Goals
*32. Select the statement which best describes your educational goals after
college:(*Required)
Select one. Take time off
Apply to MS program
Apply to PhD program
Apply to combined PhD/MD program
Apply to Medical/DO school
Apply to MPH program
Apply to PA school
Other
Undecided
*33. Please select the statement below that best describes your current career
goals:(*Required)
Select one. I am unsure of my future career goals.
I am interested in pursuing a medical/allied health profession.
I am interested in pursuing a scientific profession.
I am interested in pursuing a profession specializing in cancer.
I am interested in pursuing a medical/allied health profession specializing in oncology.
I am interested in pursuing a scientific profession specializing in cancer research.
I am interested in pursuing a combined medical and scientific profession.
I am interested in pursuing a combined medical and scientific profession specializing in oncology/cancer research.
F. Personal Statement
Based on the education and career goals you indicated in the previous questions, write a personal statement in paragraph form which answers the following three questions: (1) What is your motivation towards the educational and career goals you have chosen? (2) How will an internship in a cancer research laboratory help you to determine or achieve your educational and career goals? (3) What knowledge, skills and insight do you hope to attain from a cancer research experience?
*34. Please write or cut and paste your 250 word personal statement in the space provided
below.(*Required)
G. Internship Selection
In this section, rank your choice of available internships below. To refresh your memory of the available research internships you may wish to open or print the college internship listing on the application web page.
G. Cancer Scholar mentor selecion
In this section, rank your choices of available Cancer Scholar mentors. To refresh your memory of the available research int you may wish to open or print the Roswell Park/Howard University Cancer Scholar Mentor listing on the application web page (http://www.roswellpark.edu/education/summer-programs/cancer-scholars-application)
35. First choice (select by mentor name)
Select one. Moray Campbell
Sharon Evans
Irwin Gelman
Pamela Hershberger
Eugene Kandel
Kelvin Lee
Brahm Segal
Mukund Seshadri
Eunice Wang
Anna Woloszynska-Read
Song Yao
Jianmin Zhang
36. Second choice (select by mentor name)
Select one. Moray Campbell
Sharon Evans
Irwin Gelman
Pamela Hershberger
Eugene Kandel
Kelvin Lee
Brahm Segal
Mukund Seshadri
Eunice Wang
Anna Woloszynska-Read
Song Yao
Jianmin Zhang
37. Third choice (select by mentor name)
Select one. Moray Campbell
Sharon Evans
Irwin Gelman
Pamela Hershberger
Eugene Kandel
Kelvin Lee
Brahm Segal
Mukund Seshadri
Eunice Wang
Anna Woloszynska-Read
Song Yao
Jianmin Zhang
H. Recommender Contact Information
NOTE: Please ensure the accuracy of the information you provide. An email will be sent to your recommender in which they will be instructed that they have a deadline of November 15th, 2013 to submit their recommendation.
38. Please provide the following contact information for a faculty member or research
supervisor who will serve as a recommender. You should also inform your recommender
that they will receive an email and to check spam/junk mail in case the "roswellpark.edu"
domain was filtered.
*Recommender's last name:
*Recommender's first name:
*Recommender's official title or position:
*Recommender's school/official email address:
*Recommender's school/office phone Number: