PRISM 2023 Application Form

Office of Student ResearchBressler, Suite M-019655 West Baltimore StreetBaltimore, MD 21201410 706 3026 StudentResearch@som.umaryland.edu http://medschool.umaryland.edu/osr

Program for Research Initiated by Students and Mentors (PRISM) Application

Applicant Form

Program Website: https://www.medschool.umaryland.edu/osr/prism/

PRISM Application Deadline: extended to March 22, 2023, 11:59 p.m.

Applicant Information

First Name*

Last Name*

UMB E-mail*

Preferred E-mail

Cell Phone

Secondary Phone

U.S. CitizenU.S. Permanent ResidentOther

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Photo (Max. size 50KB, JEPG)

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All eligible and qualified persons, including those from diverse backgrounds such as those who are underrepresented in science and medicine, are strongly encouraged to apply to this program. See definitions of underrepresented in medicine by the Association of American Medical Colleges (AAMC) and description of groups underrepresented in the biomedical, clinical, behavioral, and social sciences and definition of individuals from disadvantaged backgrounds by the National Institutes of Health (NIH).

I identify myself as an underrepresented person in science and medicine.I come from an economically disadvantaged background.

Faculty Research Mentor

Main Mentor

First Name

Last Name

Title/Position

Department

Division

Institutional Email

Research Project

Project Title

YesNo

Summer Plans and Other Funding

Indicate other commitments or plans during the summer that may prevent you from participating in a portion of the Program and its activities or may pose a time conflict with the program (including PCT, Medical Genetics Course, family vacation, other traveling, etc.).

Indicate any other funding you have applied for including summer programs, fellowships, and scholarships. You must notify the Program immediately when receive decisions for these or other funding for the summer.

Short Essays

Why are you interested in PRISM? What do you hope to gain from the program?

What can you bring to the program? (skills, knowledge, experience, perspective, etc.)

Documents

Biosketch CV or Resume

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Research Plan

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Unofficial Transcript

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Additional Documents, if any

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Explanation for additional document(s)

If this is an update submission, please note what information or documents are being updated or added.

Additional Comments