Summer Research Program 2020 Invitation

Thank you for your interest in the Indiana University Simon Cancer Center Summer Research Program. This program provides hands-on research training for graduating high school seniors and college freshman and sophomores from populations underrepresented in medical research and/or disadvantaged backgrounds, according to the National Institutes of Health definitions (https://grants.nih.gov/grants/guide/notice-files/NOT-OD-20-031.html). Please read over sections A and C on that link and please provide answers as accurately and completely as possible.

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. First and Middle Name/s:

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If you have a school issued email, enter your school email here.

What is your personal email where we can write you to follow up on your application?

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Please confirm your email again

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Phone number where you are best reached?

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Name of Parent(s) or Guardian(s) that you live with. If you have a shared custodial arrangement, please add name/s of other custodial parents on the next line.

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Name(s) of Additional Custodial Parents or Legal Guardians with shared custody.

Home Address. Enter your complete address here, with city, ST and zip

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If you attend a college, university, boarding school, or other school away from your home, list your additional mailing address with city, ST and zip.

Home phone number - or number where one of your parents can be reached

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Parent email 1. Provide an email address for a parent you live with where we can send program information.

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Parent email 2. If applicable, provide an email address for the second parent you live with.

Which option best describes your current educational level:

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Describe your current educational level or grade in school

Name of Institution where you currently study

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Date of Birth

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Gender

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Race

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Ethnicity

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How did you first learn of the Summer Research Program?

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Who was the past intern? How do you know each other?

What is the name of the professor or teacher who informed you about the Summer Research Program?

Explain details of how you learned of the Summer Research Program

Please read info in sections A and C at https://grants.nih.gov/grants/guide/notice-files/NOT-OD-20-031.html Explain what in specific about your background identifies you in the NIH definition of disadvantaged or underrepresented in the biomedical, clinical, behavioral, and social sciences

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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