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Summer Health Professions (SHP) Application 2019

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1. Please complete the following information for the Summer Health Professionals Research Program 2019.

2. Project information must be completed with your mentor.

3. Your mentor must complete and sign the verification section.

4. The SHP Application will close on 3/1/2019 at 23:59.

First Name

* must provide value

Last Name

* must provide value

Middle Initial. Enter NMN if you have no middle name.

* must provide value

Address: List your complete address to include:
Resident number and apartment number if applicable.
Street name, City, State, and Zip Code

* must provide value

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Phone number beginning with area code.

* must provide value

E-mail

* must provide value

Alternate e-mail - must be different from your school e-mail.

* must provide value

Gender

* must provide value

Male

Female

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Date of birth

* must provide value

Y-M-D

Age

* must provide value

Race

* must provide value

Ethnicity

* must provide value

Hispanic or Latino

NOT Hispanic or Latino

Do not wish to provide

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Minority

* must provide value

Yes

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US Citizen

* must provide value

Yes

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List the country of your citizenship

* must provide value

Select the MUSC College you are enrolled

* must provide value

MUSC College of Dental Medicine

MUSC College of Health Professions

MUSC College of Medicine

MUS College of Nursing

MUS College of Pharmacy

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If you are not an MUSC Student, write in the Medical or Health Professional school you attend.

* must provide value

Expected date of graduation

* must provide value

Y-M-D

List your undergraduate College/University

* must provide value

Undergraduate major

* must provide value

Date of undergraduate graduation

* must provide value

M-D-Y

Do you have research experience? This question will not determine whether you are or are not accepted for an SHP fellowship.

* must provide value

Yes

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Attach a PDF document describing your research experience.

* must provide value

Upload file

Mentor's Full Name

* must provide value

Mentor's Department

* must provide value

Mentor's Title

* must provide value

Mentor's Email address

* must provide value

Project Title

* must provide value

Attach a PDF document explaining the Aims, which are the overall goal or what you hope to achieve at the end of the project.

* must provide value

Upload file

Attach a PDF document describing the Objectives of your project. The objectives list the steps that will be taken to achieve the desired outcome.

* must provide value

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Mentor's Name

* must provide value

Mentor's E-mail

* must provide value

Name of the student you will mentor

* must provide value

Do you agree to mentor this applicant during the 10 week Summer Health Professionals Research program beginning May 20st through July 26th 2019?

* must provide value

Yes

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Mentor's Signature - The application is not valid without the mentor's signature.

Click on the "Add signature" link and use your mouse to sign this form.

* must provide value

Add signature

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.