Submission deadline is February 19, 2010 (postmark).
Salutation
Mr.
Miss
Mrs.
Ms.
Dr.
First Name (*)
Last Name (*)
Nation/Tribe (*)
Gender
Social Security Number
U.S. Citizen? (*)
If no, provide citizenship
Registering for August MCAT?
Date of Birth (*)
Current Contact Information
Address 1 (*)
Address 2
City State Zipcode (*)
Phone (*)
E-mail (*)
Permanent Contact Information
Address 1 (*)
Address 2
City State Zipcode (*)
Phone (*)
E-mail (*)
Departure Airport airport from which you would be departing to Boston on 6/11/10 and to which you would return on 8/6/10
Will you have health insurance during 06/2010 to 08/2010?
Education
College 1 (*)
Dates of Attendance (*)
Major (*)
Degree (*)
College 2
Dates of Attendance
Major
Degree
College 3
Dates of Attendance
Major
Degree
Honors Awarded / Research Experience
250 Words or Less
Where did you hear about our Program?
Internet
(1) Please describe your involvement in the Native American community. Be sure to include any hobbies, cultural activities or volunteer work that may demonstrate your contribution to the lives of Native People.
250 Words or Less
If your answer to this question exceeds 250 words and you would like to upload a Microsoft Word document with your response, you may do so when you proceed to the next page.
(2) Please describe your interest in medicine or biomedical research, including what your goals are and how you hope to benefit yourself and your people by participating in the Four Directions Summer Research Program.
250 Words or Less
If your answer to this question exceeds 250 words and you would like to upload a Microsoft Word document with your response, you may do so when you proceed to the next page.
Letters of Recommendation
We would like to receive letters of recommendation that can attest to 1) your relationship to Native American communities, and 2) your academic potential. While we require a minimum of one (1) letter of recommendation, we strongly advise that you provide two (2) letters to ensure that your qualifications are well described. These letters can come from a combination of community leaders, instructors, or counselors. The letters should be sent to the address provided below.
Letters must be postmarked by February 19, 2010 (postmark) in order for your application to be considered complete.
RECOMMENDATION 1 Should be from a community leader or elder who can describe your relationship with the Native community.
Name (*)
Phone (*)
RECOMMENDATION 2 Should be from someone who can describe your academic performance, such as a former instructor, principal, dean or school counselor/advisor.
Name (*)
Phone (*)
TERMS AND AGREEMENTS
All application materials must be postmarked by February 19, 2010 (postmark). No exceptions! We will not accept letters of recommendation by FAX.
Please mail your letters of recommendation to:
All submitted materials become the property of the Four Directions Summer Research Program (FDSRP) upon receipt.
All general information about the program is available on our Web site at http://www.fdsrp.org .
Accepted applications will be notified by e-mail and/or telephone by March 5, 2010 . If you have questions about the program or your application please call Elena Muench at Brigham and Women’s Hospital (617-617-525-7644) or e-mail: FourDirections@partners.org
I have read the instructions above and agree to the terms described. You must agree to the terms and agreements in order to submit the application.
