Official LAST NAME. Please provide your LAST NAME as it appears on your social security card, or other similar official documents. If your last name is more than one word, please include it here with with caps, or no caps the way it appears on your documents -example: de la Vega.
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Official FIRST & MIDDLE NAMES. Please provide your first and middle names the way they appear on your social security card, or other similar official documents.
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If you have a school issued email, enter your school email here.
enter a valid email address to receive your confirmation
What is your personal email where we can write you to follow up on your application?
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This helps ensure accuracy
Please confirm your email again
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This helps ensure accuracy
Phone number where you are best reached?
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(###) ###-####
Which university do you attend?
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University of Notre Dame IUPUI Indiana University, Bloomington Other Indiana University Campus
Which Indiana University Campus do you attend?
Name of Parent(s) or Guardian(s). If you have a shared custodial arrangement, please add name/s of other custodial parents on the next line.
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Custodial parent/s or legal guardian/s
Name(s) of Additional Custodial Parents or Legal Guardians
Custodial parent/s or legal guardian/s
Home Address. Enter your complete address here, with city, ST and zip
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address at home
Home phone number - or number where one of your parents can be reached
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If you live away from home while you study at university, list your mailing address with city, ST and zip. If you live at home simply write 'home'.
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address at school
Which option best describes your current educational level:
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Undergraduate Year 1 Undergraduate Year 2 Undergraduate Year 3 Undergraduate Year 4 Other
Describe your current educational level or grade in school
As of now, which is your most likely plan after you finish your bachelor's degree:
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Nursing or Nurse Practitioner Physical or Occupational Therapy Pharmacy (DPharm or other) Dentistry DDS or DMD MD Medical Degree MD-PhD Combined Program Other Plans
Describe the degree you plan to pursue or other plans you have after your bachelor's degree
Date of Birth
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(DD/MM/YY)
Gender
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Female Male Non-Binary
American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White Multi-Racial Unknown
Choose most descriptive option
Ethnicity
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Not Hispanic or Latino Hispanic or Latino Unknown
Choose most descriptive option
The IUPUI Campus Housing has not made firm decisions on 2021. Even if approved, students may need to use part of their stipend to pay for summer housing. We are hoping that most/some students will have a place where they can stay within a 30 mile radius to campus. Please use the address to the Medical Library to determine distance:
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I have parents, close friends and/or relatives where I can stay within 30 miles of the campus. I would be willing to contribute part of my stipend to cover the expenses of campus housing.
Please copy and paste your personal statement into this text box. A personal statement describes why you a are interested in participating in the Indiana Clinical and Translational Sciences Institute Summer Research Program. 200 words is sufficient but longer is ok.
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personal statement essay
It is possible that the public health directives will require the 2021 summer internship to be virtual only. There are pros/cons associated with this. One benefit is that interns would still be able to participate at the IU School of Medicine while living remotely out of state or out of town. Which option best describes your position regarding 2021 summer options?
I prefer an in-person experience, but will accept virtual only I prefer an in-person experience and will decline virtual participation I am happy to participate virtual, regardless of other options.
select only one option
Optional Question. (You may skip). https://grants.nih.gov/grants/guide/notice-files/NOT-OD-20-031.html
Provide any information that can help program directors identify a placement for you according to your interests.
Enter your name on this line to certify you have completed this form with accurate information. After you click submit you need to provide your email for the system to send you the confirmation.
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Type your name here
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