Application for program

UTSA/UTHSCSA Cancer Bioinformatics Research Summer Program for UTSA Students APPLICATION FORM For priority consideration, all application materials must be received by March 20, 2016. I. Personal Information First Name: __________________________________________ Last Name:

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Birthdate:

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Gender:

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Permanent Address: Street:

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Apt/Rm #:

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City:

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State:

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Zip:

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Cell Phone:

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E‐mail:

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Are you Hispanic or Latino? (a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)

Do you have a Social Security Number? Are you a Texas Resident? Citizenship: If other, please list country and type of Visa

Yes No Yes No Yes No US Citizen US Permanent Resident Other ____________________________________ __________________________________________

Program supported by NIH/NCI grant P20 CA165589, The Cancer Bioinformatics Initiative: A UTSA/UTHSCSA Partnership and P30 CA054174, The UTHSCSA Cancer Therapy and Research Center (CTRC).

II.

Academic Information Degree Program: B.A. M.A. B.S. M.S. M.A. Other: __________________________

Academic Level:

Undergrad, 1st year Undergrad, 2nd year Undergrad, 3rd year Undergrad, 4th year Graduate, 1st year Graduate, 2nd year

Degree Field or Major:

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Expected Graduation Date:

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Major/Field GPA:

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Do you have any previous research and/or quantitative experience? If yes, please explain in your personal statement.

Yes No

III.

References Please list two references below. These references should be professors, supervisors, or other professionals who are familiar with your work. Name: __________________________________________

Title:

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Institution:

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Institution Address:

__________________________________________

Phone:

__________________________________________

E‐mail:

__________________________________________

Name:

__________________________________________

Title:

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Institution:

__________________________________________

Institution Address:

__________________________________________

Phone:

__________________________________________

E‐mail:

__________________________________________


Family Educational Rights and Privacy Act of 1974 (FERPA) Under the provisions of this Act, you have the right to see recommendations for admission. Please choose the appropriate phrase below and sign your name. I Waive Do Not Waive any right of access that I may have to this recommendation form. Applicant’s Signature: ________________________________________________ Date: _____________ IV. How did you hear about the summer program? UTHSCSA Website Student who previously participated UTHSCSA Faculty

Other website

UTSA Website

UTSA Faculty

V.

Personal Statement Submit a 1‐page letter of interest indicating why you would like to be considered for this program. Please address the following: o What interests you about this program (please be specific) o What you hope to gain from this experience o Special contributions you can make to this program o Quantitative expertise and previous research experience o Your career plans

COMPLETE APPLICATION CHECKLIST The application and supporting documents must be submitted to the Program Coordinator, Eva E. Garcia‐Rodriguez at [email protected] by March 20, 2016 in order to receive full consideration. Application form Personal Statement/Letter of Interest Resume Transcript: Submit a complete unofficial transcript that includes the courses you are currently enrolled in. Letters of recommendation: Provide 2 names as references. The program coordinator will contact recommenders directly. Please confirm that your references are willing to provide a letter prior to registration.
