AMSA Academy
Institute COMMON APPLICATION
* Required
Instructions
To complete your application, we will need to receive this completed form, your current resume or curriculum vitae (limit three pages), and your $10 processing fee. All materials should be received by the application deadline indicated on the institute's website in order for your application to be considered. If you encounter any problems using GoogleCheckout at [link to google checkout], please email dsp@amsa.org. If you have questions specific to the institute that you are applying for, please contact the institute coordinator, as listed on the program's webpage.
Institute to which you are applying:
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General Information
Name
*
School Affiliation
If applicable
Student Status
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Undergraduate Student
Pre-medical Student, post-undergrad
Medical Student, Year 1
Medical Student, Year 2
Medical Student, Year 3
Medical Student, Year 4
Medical Student, Year Off
Resident PGY-1
Resident, PGY-2 or greater
Other:
Are you pursuing a dual degree?
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No
MPH
MBA
Other Masters
PhD
Other:
Home Address
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City
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State
Zip Code
Email Address
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Essays
Personal Statement (500 words maximum). Describe your interest and experience in topic of the institute to which you are applying. Please discuss relevant leadership experiences and how the skills and knowledge gained from those experiences will help you to contribute to this institute. Please also tell us what you hope to gain by participating in the Institute.
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Project Description (250 words maximum). Describe a local project on the topic of this institute that you are proposing (or that you have previously discussed with a member of the faculty or administration at your medical school). Please include the purpose, audience, main activities, and concrete objectives of your project. Also indicate the name and title of the person advising you on the project and the resources that you will need for its completion.
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Please note that this is just a project *proposal* and that your project plans may change after attending the institute, but we would like to see that you have come up with a concrete, sustainable idea.
Additional Question (Optional)
If your particular institute requires you to answer any additional question specific to that program, you may enter that answer here. Please refer to the institute website for such requirements
Logistical Information
Please note that the information submitted in this section of the application does not affect admissions decisions. This information is used only after applicants have been accepted.
Please list the name and contact information of the dean/faculty member at your school who is responsible for providing funding for students for extra-curricular and student-life activities.
This is the person you would like AMSA Academy to contact on your behalf to request funding for your participation.
Please list the name and contact information of any mentors who you think would be particularly interested in your participation with this AMSA Academy institute.
We will notify these people with an acceptance letter if you are chosen to participate in AMSA Academy programming and may also contact them on your behalf to request funding for your participation.
Dietary Preferences:
(if any)
Emergency Contact
*
Name, Phone number, Relation
Agreement
I understand that, if accepted, I will be responsible for arranging my own travel, with expenses paid by my medical school and/or myself, to arrive at and depart from the institute at the date and times time specified by the program coordiantor. I understand that the Institute will require my full attention and I will be required to stay in the housing provided. I agree to develop and execute an educational project upon returning to my home institution, a requirement for participating in the Institute.
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Please sign your name and enter the date below if you agree to this statement.