Research Trainee Application (MSOM Medical Student ONLY)

New User Details

User ID

User ID (verify)

Password

Password (verify)

Type of Research Training (Choose One)

* Direct Supervisor Full Name

* Direct Supervisor Email Address

* Department Name

* Department Contact Full Name

* Department Contact Email Address

Personal Information

* Last Name

* First Name

Middle Name

* Date of Birth

Citizenship Status Required:

Current Address:

* Street

* City

State

* Zip Code

Telephone Number(s) with area code:

Day

Evening

* Cell

* E-mail address:

Have you ever been a trainee or a volunteer at the University of Miami?

If yes, please indicate:

* UHealth Department

Location

* Trainee Position

Start Date

End Date

Contact / Supervisor

Name(s) and Department(s) of family members employed at the University of Miami (if applicable):

Emergency Contacts

* Name:

* Relationship to you:

Telephone Number:

* Cellular Number:

Physician's Name:

Hospital Affiliation:

Physician's Telephone Number:

Education, Training, and Interest

Relevant Education - If student, indicate: Academic Affiliation

Graduation Year

Relevant training, skills, and experience:

Why do you choose to be a research trainee at the University of Miami?

Signature

I certify that all statements in this application are true. I also agree that if I am accepted as a research trainee, I will abide by all regulations of the University of Miami.

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Applicant's Signature