Community Research Fellow Application Form

Community Research Fellowship

Application for 2020-2021
In order to be considered for this fellowship, please complete this form and attach your Statement of Purpose (on the next page) by January 15, 2021.

Note: the Statement of Purpose should be no longer than 2 pages in length. See the following page for more information.

Questions? Contact Dr. Marquita Taylor: taylorm40@southernct.edu
Your Information
Name:*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Email Address*
You & New Haven
Do you currently reside or have you ever resided in one of the following New Haven neighborhoods?

Beaver HillsDixwellDwightFair HavenHillNewhallvilleWest RockWest HillsWest RiverOther
How long have you lived there?
Do you work in New Haven? If so, where?
Meeting Commitment
If accepted into the program, Fellows are expected to attend:
- mandatory orientation on Weds., January 27th at 5:30pm, and
- monthly evening meetings from 5:30-7:30pm on the 1st and 3rd Wednesday of the month.
Please check the box below to confirm your commitment to attending the monthly meetings.

I am able to commit to the monthly meeting schedule listed above.

Statement of Purpose
Please respond the the following questions and attach your Statement of Purpose below. Your Statement of Purpose should be 2 pages or less in length.
1. Why do you aspire to participate in the Community Research Fellowship program?
2. Please discuss how your past experiences and current knowledge make you uniquely qualified to serve as a Community Research Fellow.
3. Please explain how serving as a Community Research Fellow aligns with your personal or professional goals.
Upload your Statement of Purpose below*

Upload a File

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Reference Information
Please provide two references that can comment on your potential as a Community Research Fellow. Your refernces should be able to speak about your previous community engagement and/or your passion towards gaining leadership in this area.
Reference #1
Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Reference #2
Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Should be Empty:

Community Research Fellowship