Online Application Form

Instructions: Use this form to apply online for the Short-Term Training Program to Increase Diversity in Health-Related Research (STREAMS) program. Before clicking on the "submit" button at the bottom of this form, print a copy with your answers for your records. The following items also must be submitted by U.S. Mail before your application will be considered:

  • Statement of Academic Interest and Career Goals. The statement should be one typewritten page. Include your full name and social security number.
  • Academic Transcript. An official copy of your undergraduate transcript (including fall semester grades) sent by institution.
  • Letters of Recommendation. Two letters of recommendation from academic faculty.

Items marked with a red asterisk * are required.

* First Name: M.I.: * Last Name:

* Undergraduate institution:

* Date of birth:

What year in school are you?:

What is your major? Expected date of graduation:

SAT (or ACT): Verb: Math: Test Date: GPA:

* Current address:

Street:
City: State: ZIP:
Daytime Phone: Evening phone:
* E-mail address:

* Mailing address after (give date):

Street:
City: State: ZIP:
Daytime Phone: Evening phone:
Fax:
Where did you learn about this program?:


* Are you a U.S. citizen or permanent resident?: yes no
(You must be a citizen or permanent resident to participate in this program.)

** For a complete list of the included Pacific Islands, download the MS Word version of this application.

* Are you disabled or a member of an underrepresented minority group?: yes no
Please indicate the group(s) in which you would include yourself (check all that apply):

Hispanic
Black/African American
Disabled
Native American/Alaskan Native
Pacific Islander, please specify**

Rank your preferred area of interest from 1 (most preferred) to 3 (least preferred):

Most preferred:

Second choice:

Least preferred:

Comments:

Thank You!


Mail all application materials to:
STREAMS
Lifespan Health Research Center
3171 Research Park Blvd., Suite 240
Dayton, OH 45420

For more information, contact:
Valerie C. Neff, Ph.D.
STREAMS
Phone: (937) 775-1304
Fax: (937) 775-1456
E-mail: streams@wright.edu

Program Dates: June 2 through July 31, 2014.
Stipend: $4,000, plus travel expenses and housing in WSU apartments.
The application deadline is February 28, 2014.