ACTRE 2014 Application

Last Name *

First Name *

Middle Initial *

Current College/University *

Campus Mailing Address *

City *

State *

Zip code *

Campus Phone *

Effective Dates for above campus contact information *

Permanent (Home) Address *

City *

State *

Zip code *

Permanent Phone *

Effective Dates for above permanent contact information *

Email Address *

Effective dates for email address above

Do you check this email address at least weekly *

Yes

No

Research Interests: List your current mentors and/or research areas of interest (Please list four). *

0/4000 characters

PERSONAL INFORMATION

This information is voluntary and refusal to provide it will not subject you to any adverse treatment. This information will be kept confidential and will be used only in accordance with Title VI of the Civil Rights Act of 1964 and Title IX of the Education Amendment of 1972. This information is used by Emory University and Morehouse School of Medicine to track program application trends.

Ethnicity/Race

Gender *

Date of Birth * +

Place of Birth (Town, State and Country)

ELIGIBILITY DETERMINATION

This information is used by Emory University and Morehouse School of Medicine to determine eligibility for the CPDR research scholar program and to track program application trends. Your responses to these questions will be kept confidential.

I qualify for the CPDR research scholar program because I am an individual *

from a racial or ethnic group that has been shown by the NSF to be underrepresented in health-related sciences.

with a disability that substantially limits one or more major life activities

from a financially, socially, culturally, or educationally disadvantaged background.

Are you a US Citizen *

Yes	No (If no, of what country are you a citizen?) No (If no, of what country are you a citizen?)

If not a US Citizen, indicate visa type:

ACADEMIC INFORMATION

What is your expected graduation date? +

By next summer, your total credit hours will make you a: *

Are you enrolled as a full-time student? *

Yes

No

What is your major? *

What is your minor? *

What is your overall GPA? *

What is your GPA for all science courses? *

RESEARCH PROGRAM INVOLVEMENT

This information is requested to avoid funding conflicts that may jeopardize undergraduate research programs at our institutions and yours. Specifically, an individual should not be paid twice for a given period of research experience. This information will only be relevant in the event of an award; participation or lack thereof will not affect the review of your application to the ACTRE program.

You are participating in a research program at your home institution that is funded by the U.S. government. (Examples of such programs are M.A.R.C. and M.B.R.S.) *

No

Not Sure

Yes (If yes, please provide the name of the program) Yes (If yes, please provide the name of the program)

Please provide the name, phone number and email address for the person that runs this program at your home institution. *

Will you receive pay from this program during the summer months and academic year?

Yes

No

Not Sure

AVAILABILITY & SUMMER HOUSING NEEDS

The 2014 ACTRE Summer program will run from May 27 -August 1, 2014

Will you be available for the duration of the program (see above)? *

Yes	No (Please explain any conflicts) No (Please explain any conflicts)

Are there any periods (5+ days) during the program when you would not be able to participate? If so, when? *

Will you require summer campus housing? (on-campus, shared double occupancy room) *

Yes

No

Upload Transcript

Upload Science Mentor Letter of Recommendation

Upload Faculty Member Letter of Recommendation

Upload 500 Word Essay on Reproductive Science Research

Upload 500 Word Essay on Why you wish to Pursue Doctoral Study

ACTRE 2014 Application Check List

Have you included the following to officially apply for the 2013 ACTRE Program? *

Completed Application Form

Transcript (may be unofficial)

Letter of recommendation from a science mentor

Letter of recommendation from a faculty member

500 word essay on why you wish to participate in reproductive science research

500 word essay on why you wish to pursue doctoral study

All Applications and its components will be due by 5pm, March 14, 2014. Late documents submissions will NOT be accepted. Please forward all paperwork to:

Ms. Felicia Underwood

Deparment of Gyn/Ob

Emory University School of Medicine

1639 Pierce Drive, Suite 4217 WMB

Atlanta, GA 30322

funderw@emory.edu