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University of Michigan

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Summer Student Application

Submitted by vittala on Mon, 12/12/2011 - 10:24am

Instructions:

Please complete this application either online or send by mail, FAX, or e-mail to:
Denise Taylor-Moon, O'Brien Center Administrator
Phone: 734-615-5020 | Fax: 734-615-6005
Room 206 Simpson Memorial, 102 Observatory, Ann Arbor, MI 48109-5725
If you are not a University of Michigan student, you must obtain a letter from the Dean/Registrar of your Medical School indicating that you are a student in good standing and send it in with your application
If you are NOT a U.S. citizen, please upload documentation which certifies your U.S. permanent residency status (a PDF copy of your green card)
Submit your application by March 1, 2012.

Notifications regarding the Program will be sent out the week of March 26, 2012.

For questions and information about registration and the program, please contact Denise Taylor-Moon at 734-615-5020, or dltmoon@umich.edu.

First Name *

Last Name *

Mailing Address *

City *

State *

Zip Code *

Cell Phone *

Area Code-XXX-XXXX

Home Phone *

Area Code-XXX-XXXX

Email Address *

Email Address - Other than U-M

Medical School Name *

Medical School Classification as of 2/1/2012 *

M1

Entering M1

Other

Date of Birth *

Gender *

Female

Male

Student ID (if U-M)

Are you a U.S. Citizen or a Permanent Resident? *

Citizen

Permanent Resident

You must be a U.S. Citizen or U.S. Permanent Resident to participate in this Program. For non-U.S. Citizens, please make a copy of your Permanent Resident Card (green card).

Race/Ethnicity

American Indian or Alaskan Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or other Pacific Islander

White

Other

Why are you interested in Nephrology and/or Hypertension related research? *

Write a 1 page essay describing your interest in kidney research. Your essay should include the type of research experience desired, ie. basic science, clinical, combination, medical education¬

What was your undergraduate major? *

What was your undergraduate minor? *

Provide name of undergraduate institution *

Provide year of graduation *

Provide your undergraduate grade point average *

Provide your MCAT scores *

Briefly describe any prior research experience.

Please indicate your current thoughts about long-range career plans and goals *

Please indicate your research preferences: *

Animal Research

Cell Biology

Clinical Research

Basic Science Research on Humans

Any Research

Please indicate your research interests *

Chronic Kidney Disease

Dialysis

Glomerulonephritis

Kidney Development

Hypertension

Molecular Genetics

Acute Kidney Injury

Systems Biology

Other or Uncertain

George M. O'Brien Kidney Center - University of Michigan Medical School
1150 West Medical Center Dr. | Rm. A520C MSRB 1 | Ann Arbor, MI 48109-5657
Phone: (734) 615-5020 - Fax: (734) 615-6005 - Email: dltmoon@umich.edu