DEMO: Summer Clinical Research Program, Pediatrics

Name*

First Last

Current Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code United States

Is your permanent address different from your current address?

Yes

Permanent Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code United States

Phone*

Gender*

Male
Female

Email*

Date of Birth*

Required Documents

Resume*

Max. file size: 80 MB.

Transcript (Unofficial)*

Max. file size: 80 MB.

Where do you see yourself in 5 years and what do you hope to gain from this experience?*

(Maximum 1000 words)

Current Status

Name of Current School*

Major(s)*

List 1st, 2nd, etc.

Minor(s)*

List 1st, 2nd, etc.

College Level*

Graduation Date (month/year)*

Comments/Other

Additonal Information

Name of Emergency Contact*

First Last

Emergency Contact Phone Number*

Relationship to Emergency Contact*

Did someone related to Hackensack University Medical Center recommend you?*

Yes
No

If so, who?

First Last

Relationship

Notice:
Federal, state and local law prohibit discrimination because of age, race, creed, color, religion, sex, national origin, citizenship status, disability or sexual preference. I certify that all matters contained in this application are true, authorize their investigation and agree that any misleading or false statements would render this application void and would be sufficient cause for immediate dismissal from the program. I understand that acceptance into the program is subject to a satisfactory completion of a medical examination and receipt to two satisfactory references. I acknowledge that I will treat as confidential all information that I may read or hear, directly or indirectly. If accepted for the program, I agree to conform to the rules and regulations of Hackensack University Medical Center. I understand that I will be required to attend an Orientation Program and participate in any training specific to my assignment. I acknowledge that Hackensack University Medical Center may discontinue my status at any time and for any reason.

Please check to indicate you have read the above notice and agree to its terms.*

Yes, I've read and agree to the notice.