APPLICATION FOR PUBLIC HEALTH SUMMER FELLOWS PROGRAM

AND INTERNSHIP FOR MINORITY STUDENTS

LAST NAME: FIRST NAME: MIDDLE INITIAL:

DATE OF BIRTH: (ex. 01/01/19??) SOCIAL SECURITY NUMBER:

CURRENT ADDRESS:

CITY: STATE: ZIP CODE:

PERMANENT ADDRESS:

CITY: STATE: ZIP CODE:

CONTACT INFORMATION:

HOME TELEPHONE: CELLULAR PHONE:

E-MAIL ADDRESS:

INDICATE THE TELEPHONE NUMBER WHERE WE CAN BEST REACH YOU DURING THE MONTHS OF APRIL (1) AND MAY (2)

CITIZENSHIP: ARE YOU A CITIZEN OF THE UNITED STATES?

YES NO: ( U.S. Citizenship is required for acceptance into program)

GENDER: FEMALE MALE

ETHNICITY: AFRICAN AMERICAN

ASIAN AMERICAN/PACIFIC ISLANDER

AMERICAN INDIAN/ALASKA NATIVE

LATINO AMERICAN OR HISPANIC DESCENT

OTHER

IF ACCEPTED, DO YOU PLAN TO DRIVE TO THE PROGRAM? YES NO

COLLEGE/UNIVERSITY:

ADDRESS:

CITY: STATE: ZIP CODE:

CURRENT EDUCATIONAL LEVEL: JUNIOR SENIOR RECENT GRADUATE

WHAT IS YOUR MAJOR?

LIST SCIENCE AND/OR MATH COURSES COMPLETED:

CURRENT CUMULATIVE G.P.A.

List your extracurricular activities (both in and outside of school; including volunteer work, community service projects, health related experiences, or explain other ways) in which you have been involved in improving the quality of community life.

Have you participated in any other summer programs? Please list as follows:

Program Name Location Contact Person/Tel #

Have you applied or been accepted to any graduate study programs?

YES NO

Do you have any computer skills?

	NONE	BASIC	INTERMEDIATE	ADVANCED
MS word
Word perfect
MS excel
Lotus 123
MSAccess
SPSS
Other

The evaluation of this program depends on our being able to contact participants in the future. Please list the name, address and telephone number of a close relative who will know how we my contact you in the future years:

EMERGENCY CONTACT PERSON (PARENT OR GUARDIAN)

LAST NAME:FIRST NAME

RELATIONSHIP TO APPLICANT:

ADDRESS:

CITY:STATE:ZIP CODE:

HOME TELEPHONE: WORK TELEPHONE:

ESSAY QUESTION: Please describe your interest in graduate studies and your thoughts about a future career. Do you have a career goal? What do you hope to gain from the summer experience we offer?
NOTE!!! Limited form size. (2000 characters)

Please verify that the information you have provided to us is accurate and true.

Applicant’s Signature:________________________________________Date:___________________

Click on 'Print' to complete application.
Please use additional paper to complete essay.
Application Deadline February 27, 2009 5:00pm EST

Completed applications will be processed upon receipt.

Early submissions are strongly advised.

Final decisions are made on/or before March 20, 2009.

Send:

· Application (Don’t forget to include statement of interests)

· (2) Letters of Recommendation (One from a College Professor)

· (1) Current Resume

· Please arrange to have official records of your grades sent directly from your college or
university. All transcripts must be received before the application deadline.

NOTE*  All application materials (other than transcript) must be packaged and received together, not separately. .

TO: Morehouse School of Medicine

Public Health Summer Fellows Program

Attention: Program Coordinator

720 Westview Drive, SW

NCPC Building, Room 336

Atlanta, Georgia 30310-1495

Sponsored by:

Morehouse School of Medicine

Centers for Disease Control

Emory University Rollins School of Public Health