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2016 SUMMER UNDERGRADUATE RESEARCH PROGRAM

Domestic StudentApplication Form

SECTION 1 Student Information
LastName: / Middle Name: / FirstName:
Permanent Mailing Address:
Telephone (home): / Telephone (mobile):
Primary E-mail: / Alternate E-mail:
Please Note: E-mail is the primary mode of communication in this program, please supply an e-mail address you access regularly.
Social Insurance Number(SIN)#: / Date of Birth (dd/mm/yy):
Educational Background
Degree Program / University / Year of Study / Major/Minor(if applicable) / Cumulative GPA to date
(3.3/4.0 or 77 % +)
Attach electronic copy of:
  • Most recent originaltranscript(s) or institutional statement of results in PDF.*If submitting institutional grades (medical students), departmental attestation/official letter (with institutional seal and signature) is required.
*Hard-copy transcripts will not be accepted.*
  • Resume (no longer than 2 pages in word.doc format)clearly highlighting scientific awards, abstracts, presentations and publications.

SECTION 2 Supervisor Information(must be IMSGraduate Faculty member)
** For a list of current IMS faculty, consult our list of faculty recruiting undergraduate summer students or visit our graduate recruitment list.
Last Name: / First Name:
Telephone (office): / E-Mail:
SECTION 3 Research Topic
Title:
Keywords (minimum 5):
SECTION 4 Research Area(please choose ONEoption that closely matches your research area)
Arthritis (AR) / Kidney/KidneyRelated (KD)
Cancer/Cancer Related (CA) / Respiratory Diseases (RE)
Cardiovascular/Heart (CHD) / Respiratory, Circulatory, and Heart Diseases (RC)
General Medicine (GM) / Other Areas of Research (O) (specify)

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SECTION 5 Funding Agreement (please choose only ONE of the following options)
All participants are required to have a funding package of $1600 CDN/month for 3 months (June, July, and August) for a total of $4,800. With your supervisor, please choose one of the funding options below:
Option 1: External Peer Reviewed Funding
The student meets eligibility requirements and has received full funding from an external source (i.e. peer-reviewed granting agency). All students are encouraged to apply for external funding. The University of Toronto Faculty of Medicine Research Office issues a list of summer student funding opportunities on their website. Click here for details.
Option 2: Full Stipend from Supervisor
The student meets eligibility requirements and will receive full funding from the IMS supervisor (i.e. through an operating grant stipend). The supervisor will provide 3 payments of $1,600 CDN to the student in June, July and August for a total of $4,800. The IMS office is not responsible for routing/administering these funds.
Option 3: Joint Funding through the IMS and the Supervisor
Completion of this subsection ensures that eligible students will be entered for the IMS award competition. A limited number of awards are made available each year and acceptance is based on funding availability.
  • Limit of one (1) joint funded applicant per supervisor.
  • Students must have an average of A- (3.7/4.0 or 80%) or higher Cumulative GPA.
  • Successful applicants will receive an IMS award of $800/month (June – August; $2,400 CDN total) via IMS. The supervisor is responsible for providing the balance of $800/month (June – August; $2400 CDN total). *IMS is not responsible for administering/routing the supervisor’s portion of this funding.
  • When applying for joint funding, student and supervisor should come to an agreement on alternate plans if the joint funding application is not successful.
  • Students who receive external funding or gain admission into another summer program,or withdraw from IMS summer program for other reasons, must inform IMS as soon as possible, consequently foregoing their funding through the IMS.

SECTION 6 Funding & Program Agreement – Contract Sign-Off

STUDENT: I agree to the conditions of my acceptanceand meet all eligibility criteria outlined under Section 5 of this application. I hereby certify that all components of my application are true. I agree to the terms of the funding agreement option that I have chosen.

______

Student Name (please print)

______

Student Signature

______

Date (dd/mm/yy)

SUPERVISOR: I agree to the terms and conditions of this agreement. If funding agreement option 2 or 3 was chosen: I agree to the terms of the funding agreement and to abide by the financial obligation to my student. I agree to pay the student under my care three (3) timely installments of $1600 CDN/month over the course of three (3) months (June, July and August). All payments for my portion of the student agreement will be made through my home department or hospital affiliate and will not be administered/routed by the IMS.

______

Supervisor Name (please print)

______

Supervisor Signature

______

Date (dd/mm/yy)

Please sign, scan this page and attach as PDF.

APPLICATION CHECKLIST:
Complete Section 1 – 5.
Scan signed copy of Section 6 and submit in PDF format.
Scan the most recent copy of transcript or institutional grade results and submit in PDF format.
*If submitting institutional grades (for medical students), attestation/official letter confirming the document’s authenticity (institutional seal and signature), is required.
Attach resume in word.doc format.

E-mail complete application to:

Elena Gessas

Email:

Phone: (416) 946-8286

APPLICATION DEADLINE: Tuesday, February 16, 2016 at 5:00 pm EST

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