First name:
* must provide value
Last name:
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Date of Birth (MM-DD-YYYY):
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Today M-D-Y
Citizenship:
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U.S. citizen
Permanent resident
Foreign
Place of permanent residency:
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Current enrollment:
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Current year in school:
* must provide value
Cell/home Phone
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School Email
* must provide value
Personal Email
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Mailing/Campus housing address: Dormitory or Housing Complex
Mailing/Campus housing address: Number and Street
Mailing/Campus housing address: City/Town
Mailing/Campus housing address: State
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Mailing/Campus housing address: ZIP code
Residential address: Number and Street
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Residential address: City/Town
* must provide value
Residential address: State
* must provide value
Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
Residential address: ZIP code
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The following demographic information is requested on a voluntary basis. It is being collected for purposes of tracking demographics of the applicant pool ONLY and is NOT considered in the review of applications.
African American
American Indian or Alaskan Native
Asian (originating from Far East Asia, South East Asia, Indian Subcontinent)
Pacific Islander (including Fijian, Hawaiian, Samoan)
Latino (including Mexican American; not Puerto Rican)
Puerto Rican
White, Anglo, Caucasian American (non-Hispanic)
Male
Female
Is anyone in your immediate family in a scientific or health-related profession?
Yes
No
Name of School
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School address: State
* must provide value
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Anticipated graduation date (MM/DD/YYYY):
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Today M-D-Y
Degree Sought
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BSN Other
Special Program (i.e. Honors)
Cumulative GPA
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Scale to determine GPA
* must provide value
4.0
3.0
100%
Pass/Fail
Other
Awards and achievements
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Society and club memberships
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Officer/leadership positions
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Have you participated in previous internships or have prior research experience
* must provide value
Yes
No
Select the type(s) of research experience(s) in which you participated
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Extramural High School Internship
Intramural College Honors/Thesis Research
Extramural College Internship
Roswell Park Summer Research Program- High School
Roswell Park Summer Research Program- College
Informal internship at Roswell Park Cancer Institute
Other
Other type of research experience:
* must provide value
Project Title/topic of MOST RECENT research experience
Research Supervisor of Most Recent Research Experience
* must provide value
Site of Most Recent Research Experience ( Department and University/Institution)
* must provide value
Site of most recent research experience (State):
* must provide value
Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
Have you given scientific talks or presentations?
Yes
No
Type(s) of presentation(s) given:
* must provide value
Most RECENT presentation Title/Topic
* must provide value
Most RECENT talk -site (ie Department & University or Conference name):
* must provide value
Most Recent Site of Talk (State):
* must provide value
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Year of most RECENT talk:
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Select the statement that best describes your current career goals:
I am unsure of my future career goals. I plan on pursuing a medical/allied health profession. I plan on pursuing a medical/allied health profession specializing in oncology. I plan on pursuing a combined medical and scientific profession. I plan on pursuing a combined medical and scientific profession specializing in oncology/cancer research.
Based on the education and career goals you have selected, write a personal statement which answers the following three questions in paragraph form (LIMIT TO 300 WORDS):
(1) What is your motivation towards the educational and career goals you have chosen?
(2) How will an summer research experience in a cancer research clinic help you to determine or achieve your education and career goals?
(3) What knowledge, skills and insight do you hope to attain from a clinical cancer research experience?
* must provide value
Provide the following contact information for a reference. This should be individual who can assess your academic or research abilities for example: a professor, research supervisor or advisor. Be sure to request permission from the individual to serve as a reference.
An email containing a link to an on-line recommendation form will be sent to your reference to complete on your behalf. To ensure timely receipt of the form: (1) be sure that the contact information you provide for your reference is accurate and (2) inform each reference that they should add the "roswellpark.org" domain to their safe-list in their email account so that it is not spam-filtered.
Reference first name
* must provide value
Reference academic/employment title
* must provide value
Place of employment
* must provide value
Work/school email
* must provide value
Work/School Phone
* must provide value
How did you learn about the program?
Answer the following question regarding your application:
Answer the following question to waive the right to review your recommendation and supporting application materials (This is done to assure candid responses from y our recommenders)
* must provide value
Complete the application process by paying the $35 non-refundable application fee.
Take the following steps:
1.) Cut and paste the URL below or open the link in a new browser to navigate to the payment portal where you can pay by credit card or receive instructions to pay by check:
https://cmetracker.net/RP/Login?formname=RegLoginLive&EventID=37058
2.) Be sure when logging into the payment site, you enter the information of yourself as the applicant.
3.) HIT SUBMIT button below on application page.