Vanderbilt University Department of Anesthesiology
Summer Internship Program Application 2016
Complete applications are due by January 31, 2016.
This is a fillable Word document. When field is selected for data entry it will be highlighted. Fill in and
save your completed form before sending.
Section I: General Information
Name (last, first): Click here to enter text.
Student Classification (Indicate year of study in space provided, i.e., freshman, 3rd year, etc.)
☐ High School Student
☐ Undergraduate Student
☐Graduate Student- Masters, PhD
☐ Medical Student:
Name, location of institution currently attending:
Major:
GPA:
Anticipated Graduation Date:
Graduation date (Post-baccalaureate students only):
My highest educational goal:
☐ Bachelor’s Degree
☐ Master’s Degree
☐ Doctorate/Professional Degree (e.g., MD, PhD, DrPH)
My career goal:
I learned about the Vanderbilt University Summer Anesthesiology Program from:
☐ Website
☐ Career Center
☐ Classmate/Friend
☐ College Professor/Advisor
Date of Birth (month/date/year):
Gender:
Female: ☐ Male: ☐ Other: ☐
Vanderbilt University Department of Anesthesiology
Summer Internship Program Application 2016
Local Address:
Street Address:
City:
State:
Zip Code:
Permanent Address:
Street Address:
City:
State:
Local Phone:
Zip Code:
Cell Phone:
Home Phone:
Email:
Section II: Short Answers
Please respond to each question in 250 words or less.
1. Describe your past community service, leadership, and/or research experiences.
2. How does participation in the Vanderbilt University Summer Research Program with the
Department of Anesthesiology fit with your short-term and long-term academic goals? Be
specific.
3. List any programming skills and/or experience with statistical software packages (SAS, SPSS,
STATA, Matlab, etc.)
4.
List any laboratory or clinical research skills and/or experience.
Vanderbilt University Department of Anesthesiology
Summer Internship Program Application 2016
Section III: Application Checklist
☐ Completed Section I and II
☐Resume or Curriculum Vitae
☐Official University/School Transcript
☐ One letter of reference from a professor or advisor at your university or school. Mailed letters must
be sealed and have recommenders’ signature across the back of the sealed envelope.
Acknowledgement
By my signature, I acknowledge that the information contained in this application is true and accurate to
the best of my knowledge and agree to being contacted in the future.
Signature (type if submitting electronically, sign if submitting paper copy:
Date:
Complete applications are due by January 31, 2016. Applications may be
submitted by email, fax or mail, but must be received by the deadline.
Mailing Address:
Joyce Speer
Office of Educational Affairs
Department of Anesthesiology
2301 VUH
1211 Medical Center Drive
Nashville, TN 37232-7237
Email Address:
Joyce.Speer@vanderbilt.edu
Fax number: 615-936-3412