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SURP 2016 INTERNATIONAL STUDENT Application Form
SECTION 1: Personal Information
First Name / Insert photo of student

Family Name
Gender / Male Female
Date of Birth / Date Month Year
Permanent Mailing Address
Email Address
**Please note: e-mail is the primary means of communication in the SURP program. Please provide an
e-mail address you check regularly.**
Alternate Email Address
Telephone #
(country code+city code+area code)
Emergency Contact Name
(indicate relationship):
Emergency Contact Telephone #:
Educational Background
Degree Program
University
Current Year of Study
Area of Study
** Attach scanned copy of most recent transcript. If applicable: include English certified translation **
Academic Distinctions or Awards
(please list)
Previous Research Experience
(please list)
Statement of Interest
(Why are you interested in participating in this program and how will it further your career goals?)
Maximum of 250 words!
SECTION 2: IMS Supervisor
Supervisor’s First Name and Family Name
* must beIMS faculty member *
Supervisor’s E-mail
Office Location / Address
Phone Number

SECTION 3: Terms of Summer Undergraduate Research Program

Home University to provide:

  • All costs related to health insurance and Canadian study permit/visa application fee.
  • All costs related to travel.
  • A total student stipend ofCDN$4,800 (provided by the supervisor) towards food, accommodation and other living expenses while in Toronto.
  • Out of the $4,800, you will be contributing$1,850towards accommodation while in Toronto. In order to reserve accommodation and secure a place in the IMS Summer program a deposit of CDN $100 must be paid upon confirmation of acceptance of this application. These expenses must be paid out in the form of acheque, money order or bank draft to the University of Toronto c/o Institute of Medical Science.

The remainder of the non-refundable Accommodation payment is due April 1, 2016.

All payments must be sent to:

SURP 2016 Accommodation

c/o Kamila Lear

Institute of Medical Science, University of Toronto

1 King’s College Circle, Rm.2374

Toronto, ON M5S 1A8

Canada

Institute of Medical Science, University of Toronto to provide:

  • Booking of accommodation in Toronto for duration of program at a Residence
  • Program Orientation
  • Weekly seminar series to complement research
  • Access to IMS Student Association social events

Institute of Medical Science faculty supervisors to provide:

  • A laboratory work environment for students
  • Research resources required to successfully perform the summer research project

By signing below you agree to the terms and conditions, individual responsibilities and financial obligations as outlined above.

SECTION 4: Consent
Student (First name, Last name):
/ Signature:
Student’s home University: / Signature :
Coordinator (First name, Last name):
Coordinator’s Phone number (country code + city code + area code):
Coordinator’sE-mail:

Summer Undergraduate Research Program (SURP) 2016

SUPERVISOR Agreement Form

(to be signed by selectedsupervisor and returned with the Application Form)

I ______confirm the arrangements for the participation of

(Insert your name)

______in theIMS Summer Undergraduate Program (SURP) from

(Insert applicant’s name)

June 1– August 26, 2016.

I will serve as his/her supervisor and will provide a laboratory work environment as well as research resources required to successfully perform the summer research project. I will provide a lab orientationfor the student, as needed, upon arrival.

______(Signature) (Print name) (Date)

Submission Instructions:

  • Application form must be completed and submitted electronically in a Word (.doc) format.
  • SURP 2016signed Agreements must be submitted in a PDF format.
  • Transcripts must be submitted in a PDF format. Any other format will not be accepted.
  • Please submit using the following e-mail subject line: SURP International (insert last name).

Return this complete form (SECTION 1, 2, 3 & 4), Agreement Letter, Supervisor Agreement form (Page 5) and scanned copy of most recent transcript to Elena Gessas at

DEADLINE for Submission: Wednesday, February 17, 2016at 5:00 PM EST.

Faculty of Medicine

Medical Sciences Building, 1 King’s College Circle, Room 2374, Toronto, ON M5S 1A8 Canada

Tel: +1 416 946-8286  Fax: +1 416 971-2253  

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