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??) STUDENT AGE: 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

                       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.


             

             

             

 

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? years:


                   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 26, 2010 (must be postmarked by 5:00pm EST)


Completed applications will be processed upon receipt.

Early submissions are strongly advised.

Final decisions are made on/or before March 25, 2010.

 

 

Please be sure your completed package includes the following: 

·         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.

 

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