APPLICATION REQUIREMENTS FOR SUMMER STUDENTSHIP AWARD

(February 2015)

(1)Number of copies

One paper copy and a PDF copy of the complete application are required, as follows:

i.1 paper copy of the completed application form (with original signatures), plus the original copy of the required Proposed Supervisor’s Letter-of-Support and Academic Transcripts. The letter-of-support and transcripts must be appended to the back of the application form. The entire paper copy of the application must be stapled in the upper, left-hand corner; do not clip individual sections of the application separately.

ii.1 PDF copy of the complete application emailed to Joanna Valsamis, Program Director, Research Funding at . The PDF must be a single file containing all sections of the application form and all appended pages, etc., in the correct order. Both sides of the transcripts, front and back, must be copied in the PDF. Applicants must ensure that transcripts in the PDF are clear and legible. If needed, combine multiple PDF files into a single file before emailing. The PDF must also have bookmarks to each individual section in the application form (i.e. Sections A to H plus Proposed Supervisor’s Letter-of-Support and Academic Transcripts; create bookmark links to go to these specific sections of the application). The file must be named as follows:

Surname_given name_CFC summer student 2015 (i.e. Smith_Jane_CFC summer student 2015)

(2)Completion of application

Sections A-C of the application form must be completed by the applicant. The supervisor is responsible for Sections D-H.

(3)Deadline for submissions

The deadline for receipt of an application is Monday, February 2, 2015. Completed applications and all supporting materials will be accepted only if courier-marked on or before midnight on the deadline day of February 2nd OR hand-delivered to Cystic Fibrosis Canada’s office by 5:00 p.m. EST on February 2nd. Applications sent by courier must have guaranteed next-day delivery. Incomplete and/or late applications will be returned to the applicant.

Applications with supporting documentation must be sent to: Research Programs, Cystic Fibrosis Canada, 2323 Yonge Street, Suite 800, Toronto, ON, M4P 2C9, (416) 485-9149.

Cystic Fibrosis Canada will acknowledge receipt of an application, via email, to the applicant and proposed supervisor by February 13th.

(4)Supporting documentation

i. Transcripts

For applicants in 1st or 2nd year university, both high school and undergraduate transcripts are required, and must be included with the original copy of the application form as well as in the PDF.

For applicants in 3rd or 4th year university, undergraduate transcripts only are required, and must be included with the original copy of the application form as well as in the PDF.

-2-

Applicants are required to inform Cystic Fibrosis Canada of any examination results received within one month following the submission deadline. These results may be submitted in the form of a letter countersigned by the course instructors concerned.

ii. Letter-of-Support

A letter-of-support from the applicant's supervisor, with original signature, must be appended to the paper copy of the completed application form (after Section H) and included as part of the PDF file submitted by the February 2nd deadline.

Please contact Joanna Valsamis, Program Director, Research Funding () if you have any questions.

PLEASE REMOVE THESE TWO COVER PAGES PRIOR TO PRINTING AND SUBMITTING THE APPLICATION FORM WITH ORIGINAL SIGNATURES AND CREATING A PDF COPY.


APPLICATION FOR CYSTIC FIBROSIS CANADA SUMMER STUDENTSHIP (February 2015)

Sections A-C must be completed by the applicant. The supervisor is responsible for Sections D-H.

A. GENERAL INFORMATION

NAME OF APPLICANT
Title
 Mr.  Mrs.  Ms. / Given Name / Middle Name / Surname
MAILING ADDRESS OF APPLICANT
Street Address / Suite (if applicable)
City / Province / Postal Code / Telephone
Email
Cystic Fibrosis Canada must be notified if the applicant’s mailing address changes between the February date of application and the following May.
TITLE OF PROPOSED RESEARCH PROJECT
NAME OF PROPOSED SUPERVISOR
MAILING ADDRESS OF PROPOSED SUPERVISOR
Institution / Department or Faculty
Street Address / Suite or Floor (if applicable)
City / Province / Postal Code
Email / Telephone Ext.

B. EDUCATIONAL BACKGROUND

Diplomas held

 transcripts included in the PDF and original copies appended to back of this application form; or

 transcripts not required (applicants in 3rd or 4th year university do not provide high school transcripts however, applicants must provide diploma details below)

Diploma/sDate received (mm/yyyy)Institution & City

FOR CFC OFFICE USE ONLY / Received
___/___/___ / Entered
___/___/___ / Entered
___/___/___ / Acknowledged
___/___/___
PDF
___/___/___ / Letter
______/ Transcript #1
______/ Transcript #2
______

APPLICATION FOR CYSTIC FIBROSIS CANADA SUMMER STUDENTSHIP Page 2

B. EDUCATIONAL BACKGROUND (cont’d)

Degrees held or expected

 academic transcripts included in the PDF and original copies appended to back of this application form

Degree/sDate received or expectedDisciplineInstitutionSupervisor

(mm/yyyy) (if applicable)

Distinctions/awards

Please include all pertinent awards, specifying dates held or received.

Date held or received (mm/yyyy)

Training experience

Please provide details of any research or other training experience related to this application.

C. UNDERTAKING OF APPLICANT

The undersigned hereby agrees that the conditions governing the award of a Summer Studentship, as detailed in the Cystic Fibrosis Canada Grants & Awards Guide, apply to any grant awarded under this application, and that these conditions are accepted by the applicant.

Summer Studentship Applicant
Name / Signature / Date

Sections D-H must be completed by the supervisor.

D. SUMMARY OF PROPOSED RESEARCH TRAINING

Please provide a 1-page summary (single-sided, single-spaced, 1-inch margins on all sides, in 12 point font size) of the research project on which the student will be engaged, including title, rationale, methods to be used, and its relevance to cystic fibrosis. Please note that the research project should be attainable within the three-month term of the award. No figures, tables, charts, etc. are allowed in Section D.

Please type your summary on a separate page, and insert the summary following this page. References should be included following the 1-page summary. No additional pages are allowed (i.e. no figures, tables, charts, etc.).

APPLICATION FOR CYSTIC FIBROSIS CANADA SUMMER STUDENTSHIP Page 3

E. UNDERTAKING OF SUPERVISOR

If an award is granted, I agree to accept the Student for research training in my laboratory, will spend a minimum of 5 hours per week with the student, certify that adequate resources will be available to cover the costs of the Student's research, and ensure that the student will produce and submit a final report to Cystic Fibrosis Canada's office prior to September 30, 2015.

Proposed Supervisor
Name / Signature / Date

F. UNDERTAKING OF HOST INSTITUTION

The undersigned hereby agree that the conditions governing the award of a Summer Studentship, as detailed in the Cystic Fibrosis Canada Grants & Awards Guide, apply to any grant awarded under this application, and that these conditions are accepted by this institution.

Head of Department or Dean
Name / Signature / Mailing Address / Date
Executive Authority of Host Institution (within which the research will be conducted and funds administered)
Name / Signature / Mailing Address / Date
FINANCIAL OFFICER
Title
 Dr. Mr.  Ms. / Given Name / Surname / Position
Institution / Street Address
City / Province / Postal Code
Telephone / Ext. / Email

APPLICATION FOR CYSTIC FIBROSIS CANADA SUMMER STUDENTSHIP Page 4

G. PROPOSED SUPERVISOR

Section G must be completed OR the CV module from a Cystic Fibrosis Canada research grant application may be appended OR a current curriculum vitae, which includes sources of funding and the number of publications from the last five years, may be attached in place of Section G.

NAME OF PROPOSED SUPERVISOR
Title
 Dr.  Mr.  Ms. / Given Name / Middle Name / Surname
Education

Degree/sDate receivedDisciplineInstitutionSupervisor (if applicable)

Research training (post-doctoral)

DatesInstitution Department Supervisor

Academic positions held and hospital appointments

DatesInstitutionDepartment Position

Distinctions/awards

APPLICATION FOR CYSTIC FIBROSIS CANADA SUMMER STUDENTSHIP Page 5

G. PROPOSED SUPERVISOR (cont’d)

Supervisory experience

Please list the fellow and student trainees that you have supervised/co-supervised (and are currently supervising co-supervising) within the last five (5) years. Additional pages may be added and must be inserted following this page.

NameProgram TypeDatesDegreesYear degree

(from/to)(received/expected)received

Publications

Please indicate number of publications, as follows:TotalPast five years

Refereed papers, published

Refereed papers, accepted/in press

Refereed papers, submitted

Book chapters, published or in press

Abstracts

Patents held or pending, including software

APPLICATION FOR CYSTIC FIBROSIS CANADA SUMMER STUDENTSHIP Page 6

H. OTHER SOURCES OF FUNDING

Section H must be completed OR the “Other funding sources” module from a Cystic Fibrosis Canada research grant application may be appended in place of Section H.

Please list all sources of active support and/or funds applied for, and describe the degree of overlap with this application. If additional pages are required, this page should be photocopied.

GRANT # Currently held  Applied for
Principal Investigator:
Co-Investigator(s):
Granting Agency:
Title of Project:
Hours per week:
Period of support:
Amount: $
% Overlap with current application:
GRANT # Currently held  Applied for
Principal Investigator:
Co-Investigator(s):
Granting Agency:
Title of Project:
Hours per week:
Period of support:
Amount: $
% Overlap with current application:
GRANT # Currently held  Applied for
Principal Investigator:
Co-Investigator(s):
Granting Agency:
Title of Project:
Hours per week:
Period of support:
Amount: $
% Overlap with current application:

01/2015