Yale University
School of Medicine
Academic Associate Program at the Yale Eye Center
Returning Volunteer ApplicationPlease include the following with this
application:
A clear copy of your University ID
Summer Application Deadline: Friday, Apr. 25, 2014 by 3pm at the YEC
Submission Information:
When you have finished completing this form please save an electronic copy for
yourself with the title: AAP_Application_YourName_Semester
(example: AAP_Application_JohnDoe_Summer2012)
Please email this form as a word document:
To: david.shield@yale.edu, dannylee718@gmail.com, helena.gali@yale.edu,
lisa.lin@yale.edu, jennifer.dupont@yale.edu
Subject: AAP YEC Application
Print the application, sign all appropriate forms and submit with the abovementioned documents to:
Jennifer Dupont
Yale Eye Center
40 Temple St. Suite 1B
New Haven, CT 06510
jennifer.dupont@yale.edu
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Yale University
School of Medicine
Personal Information
Name (First Middle Last):
Current Address
Street Address/Apt:
City, State, ZIP Code:
Permanent Address
Street Address/Apt:
City, State, ZIP Code:
Home Phone:
Cell Phone:
E-mail Address:
Yale Net ID (ex. jj3):
Date of Birth mm/dd/yyyy:
Emergency Contact:
Relationship:
Phone Number:
Yale College:
Are you applying for the 8 hr/week program or the 30hr/week program?
8hr/week:
30hr/week:
Did you volunteer with the program in a previous semester?
Yes
No
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Yale University
School of Medicine
Studies Being Conducted this Summer:
(Additional information about the individual studies can be found on the AAP
website)
1. Clinical chart review to examine the effects of high levels of calcium on the
retina
2. Yale Thyroid Eye Disease Specimen and Data Repository
Note: The amount of time and work that a member would like to dedicate to
these studies can be variable given the member’s summer schedule. A minimum
of 6 hours/week is required for participation; additional hours are highly
recommended. Specific schedules can be worked out with the residents who are
running the studies, and the schedules can vary on a case-by-case basis.
Tentative Scheduling Preferences:
Number your choices in order of preference (1, 2, 3, etc). Place an X next to any
shifts you cannot take. (Excludes travel time to YEC)
*Note: Please indicate the number of shifts that you would like to work (a
minimum of 8 hours/week is required for participation). A more specific and
individualized schedule can be decided with your assigned medical resident.
Shift 1
Shift 2
Shift 3
8am to 11am
11am to 2pm
2pm to 5pm
Monday
Tuesday
Wednesday
Thursday
Friday
If you have any comments about scheduling (ex: other commitments) please
write them here.
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Yale University
School of Medicine
Compliance with HIPAA
I understand that patient records including demographic, biographic, insurance,
financial, and clinical information are confidential and are subject to the
requirements of HIPAA. In the course of employment or association with Yale
University, this type of confidential information may be required and consequently
accessed from file folders, computer display screens, and computer printers. I
understand that I should only access that information which I need to perform my
work-related duties.
Release of this confidential information, either written or verbal, except as
required in the performance of work, is a critical violation of employee
conduct. As such, it may be considered reason for immediate termination and
could result in civil and criminal penalties under the Health Insurance Portability
and Accountability Act of 1996.
________________________________________
Signature
___________________
Date
By submitting this application, I affirm that the facts set forth in it are true and
complete. I understand that if I am accepted as a volunteer, any false
statements, omissions, or other misrepresentations made by me on this
application may result in my immediate dismissal.
Name:
Signature:
___________________________
Date:
___________________________
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