On-line application: 2014 Roswell Park/Howard University Cancer

Scholars Program

A. Background Information

*1. Are you a current Howard University Honors Biology Sophomore applying to the

"Howard/Roswell Park Cancer Scholars Program?"(*Required)

Select one. Yes

No (Answer question number 1.1.)

**Program Ineligibility**

Only Honors Sophomores are eligible to apply to the Roswell Park/Howard University Cancer Scholars Program. However, if you are junior, you may be eligible to apply to the Roswell Park Cancer Institute "Summer Research Experiences in Cancer Science" Program. (www.roswellpark.edu/summer-programs) Please exit from the application.

2. Provide your legal name as it appears on government-issued documents. If you do not

have a middle name, enter"none."

*First name:

*Last name:

*Middle name:

*3. Date of birth (RPCI policy prohibits anyone under the age of 14 to participate in

laboratory research)(*Required)

Enter a date on or before June 19, 1998.

4. Gender

Select one. Male

Female

*5. Citizenship(*Required)

Select one. U.S. Citizen

Permanent Resident (Answer question number 5.1.)

Foreign (Answer question number 5.2.)

*5.1 IF YOU SELECTED "Permanent Resident" IN QUESTION 3, please indicate place

of permanent residency:(*Required)

Select one. United States

Commonwealth of Puerto Rico

Northern Mariana Islands

Guam

American Samoa

Trust Territory of the Pacific

**Only "U.S. Citizens" or "Permanent Residents" are eligible to apply to the program.**

We're sorry, the eligibility requirements of targeted funding sources precludes foreign students from applying to the Roswell Park/Howard University Cancer Scholars Program. Please exit the application.

6. Are you the first generation in your family to attend college? (Optional)

Select one. Yes

No

7. Is anyone in your immediate family in a scientific or health-related profession?

(Optional)

Select one. Yes

No

*8. Temporary/school email address:(*Required)

*9. Permanent/personal email address:(*Required)

*11. Permanent/Personal cell phone number:(*Required)

12. Temporary/on-campus mailing address:

*Number and Street:

*City:

*State: Select one. Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

District of Columbia

Florida

Georgia

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

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

American Samoa

Guam

U.S. Virgin Islands

Other

*Zip Code:

13. Permanent/home address (parent or guardian address):

*House Number and Street:

*City:

*State: Select one. Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

District of Columbia

Florida

Georgia

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

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

American Samoa

Guam

U.S. Virgin Islands

OTHER

*Zip Code:

*14. If you are accepted into the program, will you require dormitory housing.

(Commuting distance must be greater than 2 hrs roundtrip by car)?(*Required)

Select one. Yes

No

B. Eligibility for targeted funding sources

Funding sources may be available that target certain populations of applicants based on being an under-represented minority or economically disadvantaged. If you believe you qualify in one or both of these categories, answer the questions in this section to apply to these funding sources. IT IS IMPORTANT TO NOTE: Acceptance into this program and the award of a stipend is based on the merits of your application. The potential source of your stipend funding is based on how you answer the questions in this section.

15. Demographic background

Select one. African American

American Indian or Alaskan Native

Pacific Islander (including Fijian, Hawaiian, Samoan)

Latino (including Mexican American; not Puerto Rican)

Puerto Rican

White, Anglo, Caucasian American (non-Hispanic)

16. Check any of the following financial aid programs for which you are eligible. This

information can be found on the "Student Aid Report (SAR)" that is created from

applying for federal student aid using the FAFSA form.

Select all that apply. Academic Competitive Grant

Federal Supplemental Educational Opportunity Grant

Federal Pell Grant

Low-income household

Scholarships for Disadvantaged Students

C. Academic Background

*17. Confirm your current enrollment status(*Required)

Select one. College/University

18. Provide the information about your current school below.

*Name of college or university: Select one. Howard University (DC)

Campus (if applicable):

*City:

*State: Select one. Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

District of Columbia

Florida

Georgia

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

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

American Samoa

Guam

U.S. Virgin Islands

Other

*Zip code:

*19. Anticipated/graduation date:(*Required)

*20. Degree sought/earned(*Required)

Select one. BA

BS

Other

*21. What scale is used to determine your grade point average (GPA)?(*Required)

Select one. 4.0 GPA

3.0 GPA

100%

Other:

22. Provide your GPA (include the most recently completed semester):

*Cumulative GPA:

*Science GPA:

*23. Select courses or course equivalents you have taken so far including those you will

take/are taking in the current spring semester.(*Required)

Select all that apply. Biology I

Biology II

Biology III

Chemistry I

Chemistry II

Organic Chemistry I

Organic Chemistry II

Physics I

Physics II

Genetics

Molecular Biology

Cellular Biology

Biochemistry

Immunology

Microbiology

Statistics

Computer Science

*24. Does your school rank students based on overall GPA?(*Required)

Select one. Yes (Answer question number 24.1.)

No

24.1 Provide your class rank. Use only the numerical ranking, for instance a "1" instead

"1st" or "first." If indicating a percentile rank, use only the integer. For instance, "10" for

top ten percentile.

*Your class rank:

*Is this a number rank or percentile?:

*Number of students in your class:

25. Provide scores for any standardized tests you have taken:

Verbal GRE:

Quantitative GRE:

Verbal MCAT/DAT:

Life Science MCAT/DAT:

Physical Science MCAT/DAT:

26. Discipline of study

*Major:

Minor:

Special Program (i.e. Honors):

27. For any science/health-related co-curricular activities in which you participate(d), list

achievements, memberships and leadership positions. For multiple items in a field(i.e.

more than one award) name each in most recent chronological order and separate by a

comma. If none, type "None."

*Awards and achievements:

*Society and club memberships:

*Officer/leadership positions:

28. If applicable, check any of the following academic programs in which you are

enrolled:

Select all that apply. Louis Stokes Alliance for Minority Participation

(LSAMP) (Answer question number 28.1, 28.2.)

Minority Access to Research Careers (MARC) (Answer question number 28.1, 28.2.)

Minority Biomedical Research Support (MBRS) (Answer question number 28.1, 28.2.)

McNAIR (Answer question number 28.1, 28.2.)

Other:

(Answer question number 28.1, 28.2.)

*28.1 Does your program provide a stipend for externships?(*Required)

Select one. Yes

No

28.2 Provide information about your specialized academic program below:

*Name of sponsoring institution:

*Name of program coordinator:

*Email contact for program Coordinator:

*Phone contact for program Coordinator:

*Allotted stipend amount:

*Duration of time funded by stipend (in weeks):

*URL to program website:

D. Previous Research Experience(s)

*29. Are laboratory research facilities and mentorship readily available at your school or

college?(*Required)

Select one. Yes

No

*30. Have you participated previously in research internships or have prior research

experience?(*Required)

Select one. Yes (Answer question number 30.1, 30.2.)

No

*30.1 Indicate the type(s) of research experience(s) in which you participated?(*Required)

Select all that apply. Intramural College Honors/Thesis Research

Extramural College Internship

Roswell Park Summer Research Program- High School

Informal internship at Roswell Park Cancer Institute

30.2 Provide the information below about your MOST RECENT research experience.

*Institution/university site of internship:

*City:

*State: Select one. Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

District of Columbia

Florida

Georgia

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

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

American Samoa

Guam

U.S. Virgin Islands

OTHER

*Zip code:

*Project topic:

*Name of research supervisor:

*Department:

*31. Have you given scientific talks or presentations?(*Required)

Select one. Yes (Answer question number 31.1, 31.2.)

No

*31.1 What type of talk/presentation did you give?(*Required)

Select all that apply. College seminar

Invited college conference

Invited scientific conference

31.2 Provide the following information about your most recent scientific talk:

*Topic/Title:

*Name of Institution Site:

*Year:

E. Education and Career Goals

*32. Select the statement which best describes your educational goals after

college:(*Required)

Select one. Take time off

Apply to MS program

Apply to PhD program

Apply to combined PhD/MD program

Apply to Medical/DO school

Apply to MPH program

Apply to PA school

Other

Undecided

*33. Please select the statement below that best describes your current career

goals:(*Required)

Select one. I am unsure of my future career goals.

I am interested in pursuing a medical/allied health profession.

I am interested in pursuing a scientific profession.

I am interested in pursuing a profession specializing in cancer.

I am interested in pursuing a medical/allied health profession specializing in oncology.

I am interested in pursuing a scientific profession specializing in cancer research.

I am interested in pursuing a combined medical and scientific profession.

I am interested in pursuing a combined medical and scientific profession specializing in oncology/cancer research.

F. Personal Statement

Based on the education and career goals you indicated in the previous questions, write a personal statement in paragraph form which answers the following three questions: (1) What is your motivation towards the educational and career goals you have chosen? (2) How will an internship in a cancer research laboratory help you to determine or achieve your educational and career goals? (3) What knowledge, skills and insight do you hope to attain from a cancer research experience?

*34. Please write or cut and paste your 250 word personal statement in the space provided

below.(*Required)

G. Internship Selection

In this section, rank your choice of available internships below. To refresh your memory of the available research internships you may wish to open or print the college internship listing on the application web page.

G. Cancer Scholar mentor selecion

In this section, rank your choices of available Cancer Scholar mentors. To refresh your memory of the available research int you may wish to open or print the Roswell Park/Howard University Cancer Scholar Mentor listing on the application web page (http://www.roswellpark.edu/education/summer-programs/cancer-scholars-application)

35. First choice (select by mentor name)

Select one. Moray Campbell

Sharon Evans

Irwin Gelman

Pamela Hershberger

Eugene Kandel

Kelvin Lee

Brahm Segal

Mukund Seshadri

Eunice Wang

Anna Woloszynska-Read

Song Yao

Jianmin Zhang

36. Second choice (select by mentor name)

Select one. Moray Campbell

Sharon Evans

Irwin Gelman

Pamela Hershberger

Eugene Kandel

Kelvin Lee

Brahm Segal

Mukund Seshadri

Eunice Wang

Anna Woloszynska-Read

Song Yao

Jianmin Zhang

37. Third choice (select by mentor name)

Select one. Moray Campbell

Sharon Evans

Irwin Gelman

Pamela Hershberger

Eugene Kandel

Kelvin Lee

Brahm Segal

Mukund Seshadri

Eunice Wang

Anna Woloszynska-Read

Song Yao

Jianmin Zhang

H. Recommender Contact Information

NOTE: Please ensure the accuracy of the information you provide. An email will be sent to your recommender in which they will be instructed that they have a deadline of November 15th, 2013 to submit their recommendation.

38. Please provide the following contact information for a faculty member or research

supervisor who will serve as a recommender. You should also inform your recommender

that they will receive an email and to check spam/junk mail in case the "roswellpark.edu"

domain was filtered.

*Recommender's last name:

*Recommender's first name:

*Recommender's official title or position:

*Recommender's school/official email address:

*Recommender's school/office phone Number: