Thank you for your interest in the Minority Health International Research Training Program at Christian Brothers University. All application materials MUST be submitted via email with the exception of your official transcripts, which can be mailed to the address listed below.
All Application Materials Must Be Received By Friday, December 19th at 5:00pm CST for priority (early-bird) consideration and by Friday, January 2nd at 5:00pm CST for all other applications. Completed applications are reviewed on a revolving basis, so early application is advisable. If you have any questions, contact the MHIRT Program Assistant, Jayanni Webster, at .
APPLICATION FORM
STATEMENT OF PURPOSE
THREE LETTERS OF RECOMMENDATION**
Recommendation forms can be downloaded from the MHIRT website. Please make sure your recommenders email your letters from their professional email addresses. Letters submitted by the applicant or through postal mail may not be accepted.
COPY of U.S. PASSPORT AND U.S. driver’s license or state ID
Please scan and send electronically. If you do not have a passport, please scan and email current U.S. driver's license or state ID.
OFFICIAL TRANSCRIPTS**
Undergraduate and Graduate if applicable. Note: all official transcripts must be mailed or received via official
electronic transmission from the university.
RESUME or CV
Optional
Updated 10/10/2014
Instructions: Please TYPE in gray fields provided. Fields will expand as needed!
CONTACT/PERSONAL INFORMATION
Name: Prefix: FIRST: MIDDLE: LAST: Date Of Birth:
School Email: Alternate Email:
Cell Phone: Home Phone: Work Phone: Preferred:
Current Mailing Address:
City: State: Zip Code:
Permanent Mailing Address:
City: State: Zip Code:
After May 15, 2015, where should we send your correspondence? This is important, because you may receive checks or other important documents in the mail.
Send to: Current Address Permanent Address Other Address (please provide):
Country of Birth:
Country of Parents’ Birth: Mother ; Father
Are you a United States Citizen or Permanent Resident? YES NO
Do you have a passport? YES NO If yes, please provide expiration date:
Do you have medical insurance? YES NO
How would you describe yourself? (Please check all that apply)
Black/African American Hispanic/Latino/Spanish Origin American Indian/Alaska Native Asian/Pacific Islander Caucasian Other (Please specify): Prefer not to answer
ACADEMIC INFORMATION
What school are you presently attending? Year of Entry:
Current GPA: Anticipated Year of Graduation:
Major or field of study: Minor(s):
Academic Standing: Undergraduate: Freshman Sophomore Junior Senior
Graduate: Masters Doctoral Medical School Other (Please specify):
Previous Research Experience: Describe any experience you have with laboratory, qualitative or quantitative research projects.
Previous International Experience: Please list any international experience and the reason for the travel.
Foreign Language Experience: Please list any foreign language experience you may have.
Please indicate your 1st, 2nd, and 3rd preference for research project (Please note- we try to match students with their preference to the best of our ability; however, project type and location are subject to change based on mentor availability at each site. This means that additional projects/countries may be added and/or the projects listed below may become unavailable):
Basic research on neuroanatomy of the visual system (Brazil)
Basic research on neurotransmitter receptor expression and function (Brazil)
Basic research on visual psychophysics (Brazil)
Aquatic environmental science: (Brazil)
Basic research on anxiety and memory acquisition (Brazil)
Basic research on neuropharmacology (Brazil)
Health Needs Assessment (Uganda)
Healthcare Systems (Uganda)
Other (Please describe):
Memphis Residents: If selected for travel to Brazil, do you agree to be tutored in conversational Portuguese two sessions per week this February – May? YES NO
Non-Memphis Residents: If selected for travel to Brazil, do you agree to undergo an independent study of conversational Portuguese in order to acquire basic proficiency? YES NO
TRAVEL SCHEDULE: Trainees are required to stay a minimum of ten weeks in the host country.
What is the earliest possible date you are available to leave the U.S. for your research site?
What is the latest possible date you would need to return to the U.S. from your research site?
Additional Information (Info provided is confidential and will not be shared outside the review committee).
Do you consider yourself to come from a disadvantaged background (e.g. racial/ethnic minority, socioeconomic; mental/physical disability; etc.) If yes, please describe.
What personal characteristics do you have that will contribute to a successful MHIRT experience?:
What personal characteristics do think will be challenged in this experience?:
Please give an example of a time that you were able to get along with other individuals despite differences in views and values:
Person to notify in the event of an emergency:
Name: Prefix: FIRST: MIDDLE: LAST: Relationship:
Address: City: State: Zip:
Email:
Cell Phone: Home Phone: Work Phone: Preferred:
Please identify any special or specific needs you might have regarding housing accommodations or transportation: Physical access needs: Allergies (food, drugs, pets, etc): Other:
Please list any medical condition you have and medication you take for that condition:
How did you hear about this MHIRT program?
Preferred T-shirt Size : XS S M L XL XXL
Statement of Purpose
The Statement of Purpose is a critical part of the application and should include:
• Why you want to conduct research abroad and how it relates to your future career objectives;
• How you will apply your study abroad experience to your academic work upon returning to your home institution;
• Why you feel particularly suited or qualified to pursue this program of study.
Please type your statement of purpose here. Write no more than 2 single-spaced pages.