IU Simon Cancer Center - Professional Education

IUSCCC William J. Wright Scholarship Fund Application

Please complete all sections on this form.

Application Deadline is April 9, 2021.

Contact Information

Applicant Name:

Email:

Date of Birth:

Gender:

M F

Permanent Address:

City: State: Zip Code:

Permanent Phone:

Cell Phone:

Demographic Information

Please check all that apply:

American Indian or Alaskan Native
Asian or Pacific Islander
Black or African American
Hispanic/Latino
White
I'd prefer not to disclose this information

U.S. Residency Status

A student must be one of the following to participate in a CRL affiliated research program:

U.S. Citizen
Permanent Resident Identification Number:
International Student Visa Status:
Other Please specify:

Education

Year in Medical School:

Expected Graduation Date:

List your research area(s) of interest:

Which of the following best describes your commitment to pursue a career in the care of Cancer patients?
Your answer here does not affect you application status.

Pediatric Hematology/Oncology
Adult Hematology/Medical Oncology
Radiation Oncology
Surgical Oncology
Other

Transcript

Please attach your academic transcript in PDF format:

Please attach your CV in PDF format:

Faculty Mentor

I have identified a faculty mentor to work with me for this program.

I need a faculty mentor and my area of interest is:

References

Please provide two references below (two references should be from a faculty member. If you have research experience, please include a recommendation from a research supervisor).

Please note: Upon completion of this form, each reference listed will receive an email requesting a letter of recommendation.

Reference 1

Name:	Position:	Please specify:
School:	Phone:
Email:	Confirm Email:

Reference 2

Name:	Position:	Please specify:
School:	Phone:
Email:	Confirm Email:

Reference 3

Name:	Position:	Please specify:
School:	Phone:
Email:	Confirm Email:

The Family Education Rights and Privacy Act of 1974, known as the Buckley Amendment, gives students the right to inspect and review their educational records. You may however, waive the right to see specific confidential letters.

I, the applicant, hereby waive my right to examine these letters and understand that it will not be shared with me.
I, the applicant, do not waive my right to examine these letters

* Failure to sign or indicate waiver status indicates confidentiality by default.

Personal Statement

Please attach a summation describing the reason you wish to pursue a career in caring for cancer patients and how you plan to do so. Also, briefly explain how your participation in this program will enhance your potential to achieve your academic and career goals. The paper should be typed, single-spaced, with standard margins, 12 pt. times new roman font, and no more than one page.

BY CHECKING THIS BOX, I HEREBY AFFIRM THAT ALL INFORMATION CONTAINED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE.

Student Signature: Date: 05/28/2022