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Application document.doc

  1. 1. SUMMER FELLOWSHIPS IN RADIATION ONCOLOGY University of Maryland School of Medicine Tina Begay, Program Coordinator Department of Radiation Oncology 22 South Greene Street, Rm GGK0101, Baltimore, MD 21201 Telephone: (410) 328-1677 Fax: (410) 328-6911 Email: tbegay@umm.edu Website: http://www.umgcc.org/radiation_oncology_program/index.htm 2010 Student Research Program Application Form Deadline: March 31, 2010 SAVE THIS FILE TO YOUR COMPUTER BEFORE STARTING When completed, attach this file to an email and send to Tina Begay at tbegay@umm.edu THIS FORM MUST BE TYPED Continued Next Page------- Last Name First Name Middle Initial Address (while attending school) City, State, Country, Zip Permanent Address (Parents) City, State, Country, Zip Telephone (cell) Email Address Date of Birth (month/day/year) Place of Birth City/State/Country I am currently enrolled in (MD/PhD or MD) Class of 20__ Citizenship: (check one) U.S. Citizen or U.S. Noncitizen National Permanent Resident of U.S. Other
  2. 2. 2010 Student Research Application ~ continued 1. When would you like to participate in this program (approximate dates): Keep in mind if selected you are expected to spend 6 contiguous weeks in the program From: To: 2. Please list, in ORDER OF PREFERENCE, the program (Radiobiology or Clinical) and faculty you would like to work. The available opportunities will be found on the Program webpage of the OSR website.  You may list up to 5 choices that you are interested in.  If you are selected you will have an opportunity to change your selection prior to matching. Example: 1st John Doe Effects of radiation on……. Clinical Choice Investigator Project Title (partial is sufficient) Clinical or Basic 1st 2nd 3rd 4th 5th 3. Please list names and addresses of the two faculty who will complete the Recommendation Form First Faculty Recommendation (required) Second Faculty Recommendation (optional) Name Title Address Address City / State / Zip Telephone Email Address Continued Next Page-------
  3. 3. 2010 Student Research Application ~ continued 4. Why did you decide to apply for this program? (Tell The Student Research Subcommittee About Yourself.) Please provide a written statement describing in 200 words or less each of the following: o Your prior research experience o Your interest in participating in this program. How will it help you? o Your area of interest: radiobiology research or clinical research (to include physics and clinicians) Continued Next Page-------
  4. 4. 2010 Student Research Application ~ continued If offered a position, I agree to (a) notify the Program of my decision in writing regarding the award within 7 days of the offer being made; (b) participate in all aspects of the program. I will submit an evaluation of the program within 30 days of the end of my training. Student’s Signature Date
  5. 5. Faculty Recommendation - Page 1 of 2 SUMMER FELLOWSHIPS IN RADIATION ONCOLOGY University of Maryland School of Medicine Tina Begay, Program Coordinator Department of Radiation Oncology 22 South Greene Street, Rm GGK0101, Baltimore, MD 21201 Telephone: (410) 328-1677 Fax: (410) 328-6911 Email: tbegay@umm.edu Website: http://www.umgcc.org/radiation_oncology_program/index.htm 2010 Student Research - Faculty Recommendation  Type or print clearly  Confine your answers to spaced provided  This form must be signed by the faculty member  Do not return this form to the student. Return it directly to the Program Coordinator at the address or fax noted above Faculty Recommendations must be received by March 31, 2010 DEAR FACULTY MEMBER: We would appreciate your candid evaluation of the student listed below who is applying for a SUMMER FELLOWSHIP IN RADIATION ONCOLOGY in the Department of Radiation Oncology, University of Maryland School of Medicine. Your comments will be held confidential. If you wish to write a letter of recommendation, in addition to filling out this form, please feel free to do so. This form must be received by March 31, 2009 (may be faxed or emailed). Your prompt response is appreciated since incomplete applications will not be evaluated. THANK YOU IN ADVANCE FOR YOUR TIME AND COOPERATION! Student Name Faculty Member Title Institution Department Address City / State / Zip Phone Number Fax Number Email Address
  6. 6. Faculty Recommendation #1 - Page 2 of 2 1. Why do you feel this applicant would benefit from a research experience? (THE PURPOSE of the medical student research training program is to encourage and introduce gifted students from all disciplines to consider careers in academic radiation oncology). 2. Approximately how long have you known this applicant? 3. How well acquainted are you with the applicant as a person? Very Well Well Marginally 4. How well acquainted are you with the quality of his/her work? Very Well Well Marginally 5. In which course(s) have you had the applicant as a student? 6. From your personal knowledge, how would you rate the applicant academically? (Check One) Upper 3% Upper 10% Upper 25% Upper 50% Lower 50% 7. To your knowledge, are there any special circumstances, financial or social, which you believe require consideration? SIGNATURE (Required): DATE:
  7. 7. SUMMER FELLOWSHIPS IN RADIATION ONCOLOGY University of Maryland School of Medicine Tina Begay, Program Coordinator Department of Radiation Oncology 22 South Greene Street, Rm GGK0101, Baltimore, MD 21201 Telephone: (410) 328-1677 Fax: (410) 328-6911 Email: tbegay@umm.edu Website: http://www.umgcc.org/radiation_oncology_program/index.htm 2010 Student Research Program ~ DEAN'S LETTER REQUEST FORM Student’s Name: Dear Dean of Student Affairs: Please send a letter stating that the above named student is in good standing in his/her medical school class to the STUDENT RESEARCH PROGRAM at the above address. This student is applying for a stipend from the Student Research Program to do research. WE MUST RECEIVE THE LETTER BY MARCH 31, 2010 or the student's application will not be reviewed. Thank you for your cooperation. Sincerely, _________________________ Coordinator, Student Research Program Student’s Signature
  8. 8. APPLICATION INSTRUCTIONS Summer Fellowships in Radiation Oncology The Department of Radiation Oncology, via an Endowment Fund for Academic Excellence in Radiation Oncology, announces the availability of two fellowship opportunities for 1st and 2nd year medical students. These 6-week programs will provide either a mentored research practicum in radiobiology or a clinical research project in health physics or clinical radiology. The stipend for either program will be $2,500 with half paid at the beginning of the program and the remainder at the end of the program when all requirements have been met. Deadline for application: March 31, 2010 Notification of Award: May 5, 2010 Selection of Mentor and Development of Project. Research projects developed by selected faculty have been competitively reviewed by a departmental committee created specifically for this purpose. The project was designed to be productive and assure to the greatest degree possible that it will be publishable and/or presented at a national meeting. Application Requirements: • Applicants must be enrolled in The University of Maryland School of Medicine • An Application that includes the following must be submitted before the application deadline: - Student Research Application Form - Student’s CV (include in order – education, training, work experience, prior research experience if any, publications or abstracts, honors and awards.) - At least 1 Faculty Recommendation (must be sent directly to the Program Coordinator) - Dean’s Letter of Good Standing (must be sent directly to the Program Coordinator) - • All parts of the application may be faxed to (410) 328-6911 (Attn: Tina Begay, Program Coordinator) or emailed with an electronic signature to tbegay@umm.edu (this method is preferred). • During the program, the student is responsible for submitting progress reports and evaluations, and notifying the Program Coordinator of any address/telephone changes. • Once your application has been received, you will receive a confirmation email from the Program Coordinator.

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