Roswell Park Cancer Institute Applied Technology Laboratory for Advanced Surgery 1 Elm Street, Buffalo, NY 14263 Reference: Junior Robotic Surgery Challenge 2015 “Dreaming doesn’t change the world, thinking does. Roswell Park allows youth to not only dream, but to think and achieve.” -Claudine Karambizi, Junior Robotic Surgeon Challenger, 2014 Dear Future Robotic Surgery Team Member, It is with great excitement that Applied Technology Laboratory for Advanced Surgery (ATLAS) at Roswell Park Cancer Institute (RPCI) welcomes high school students from the Greater Buffalo area to apply for the Junior Robotic Surgery Challenge (JRSC), 2015. After the overwhelming success of the pilot program, Junior Robotic Surgeon Challenge, 2014, the program has been expanded and honed to be implemented as an annual event. The method used for training robot-assisted surgeons at RPCI is the Fundamental Skills of Robotic Surgery (FSRS) curriculum which was validated in early 2013 as a proven method for teaching robot-assisted surgery. Students embarking on the JRSC 2015 will complete much of the FSRS curriculum supplemented by lengthy pre-course assignments, recitation discussion groups, and hands-on lab work. By the culmination of the program in the final challenge, students will be trialed on their developed knowledge, teamwork, and skills utilizing an actual surgical robot (daVinci Surgical System®) in team-based challenges. In conjunction with the final Challenge Event, ATLAS will host a job fair where students can speak with professionals in branches of STEM as well as compete for prizes with their teams. The program will begin on June 19th, 2015 and culminate on Saturday, August 8th, 2015 with a grand finale event that’s open to the public. All participating students who complete the required curriculum will receive a certificate of completion of the Introduction to Robotic Surgery and are eligible to compete for awards and prizes. The top teams and individuals will receive awards based on their performances. In order to apply for this program, please fill out and return the attached documents in digital format (email) and make sure that they are confirmed completed before the deadline,5:00pm on January 9th, 2015. The final list of JRSC 2015 participants will be announced on March 6th, 2015. Thank you for your interest in participating in this program. We look forward to your success in this year’s event! Yours sincerely, Eilene O’Brien, PhD & Khurshid Guru, MD *Co-Chairs of the Junior Robotic Surgery Competition Entry Criteria: 1. Currently enrolled High School Student from the Greater Buffalo Area a. Student Age: 15-18 years for duration of program (June 19th 2015-August 8th2015) b. Eligible: 2015 Incoming sophomores, juniors and seniors. c. Seniors: High school seniors (post-graduate) will be accepted if they consent their attendance for the full program and final event, without interference with their continued education. d. New to Program: No students who have participated in this program in previous years will be considered for the following year(s) programs. You may only participate in this program once. e. Application: College-style application with essay and letter of reference. Students are required to apply as a nurse, physician assistant, or a surgeon. (Applicants select one profession chosen in alignment with future goals) f. Cost: $400 per participant g. Scholarship Availability: A limited number of scholarships will be available and awarded based on financial need. 2. Submissions a. Current Curriculum Vitae (CV) i. Standard English, typed, 1-2 page, double-spaced, 12-point font (Calibri or Times New Roman), one-inch margins ii. Include first name, last name, highest level of education, measures of excellence, pertinent coursework, activities, volunteering, & community outreach, etc. b. Two Letters of Recommendation (LOR) specifically written for this program (Preference towards academic, one letter may be from school’s JRSC chaperone *NO family members may provide LOR) c. Essay i. Standard English, typed, 1-2 page, double-spaced, 12-point font (Calibri or Times New Roman), one-inch margins ii. Cover all of the following topics: 1. Are you applying to this program as a nurse, physician assistant, or a surgeon? (you may only choose one and your choice should align with your future goals) 2. Why should you be selected for this program? 3. What can you contribute to your robotic surgery team? 4. How has your prior course/volunteer work and life experiences prepared you to be successful in this program? 5. What future goals or aspirations will your participation in this program help you towards? 1. Formal references welcome **Some participants may be called in for an interview** How has your prior course/volunteer work and life experiences prepared you to be successful in this program? e. Completed Application Portfolio i. Participant Application Pages (pg. 5 & 6) ii. RPCI Photo Release Form (pg. 7) iii. Parental Acknowledgement, Consent and Release Form (pg. 8 & 9) iv. Teacher Chaperone Information (pg. 10 & 11) 3. Confirmation of Availability*This will be issued at a later date if you are invited to participate in this program All submissions will be accepted by email (NO HARD COPIES IN MAIL WILL BE ACCEPTED) no later than 5pm on 1/9/2015 to the following… AtlasTeam@RoswellPark.org *Please ensure that you have received confirmation from ATLAS that your submission was received before 5pm *APPLICATION PAGE: RETURN TO ATLAS Participant: Please ensure that all of your documents are digitally submitted via email (AtlasTeam@RoswellPark.org) to Erinn Field or Allison Polakiewicz by 5:00pm on Friday January 9th 2015. The list of participants will be announced by March 6th, 2015. The Participant Pledge form is due by 5:00pm on April 3rd, 2015. This year’s program will run from June 22nd, 2015 to August 8th 2015 and is a 25+ hour in-program time commitment with 10+ hour outside-program time commitment. Participants must attend three sessions of a three hour devotion between 6/15/2015 and 8/1/2015, which will be assigned and sent out by March 6th 2015 as well as several dates in late July/early August. Full Name: de: Male: _______ Female: ______ School: ________________________________________________ D.O.B. Gra Home Address: City: State: Zip Code: Email: ______________________________ Phone Number: _____________________________ Shirt Size: (S, M, L, XL) ________________________ *They run large* Please check which of the following you are applying as (Choose ONE): Nurse Physician Assistant Surgeon Special Interest Dates: The Program will run from June 15th 2015 to August 8th 2015. You are expected to be available between these dates to be able to participate in this program, however, please use the spaces below to indicate your preferred day of the week and either the morning or afternoon session, to best accommodate you. Select Day & Session Time in Order of Preference DAY (M,W,F) 1. ___________ _____________ 2. ___________ _____________ 3. ___________ _____________ AM/PM SESSION Special Accommodations: Please feel free to let us know of any communication, mobility, learning, or other potential barriers to your success that we should know about in order to make this program safe and accessible to your needs (*Note: Absolutely nothing you write in the section below will be taken into account in the assessment of your eligibility to participate in this program nor will it be seen by anyone but the co-chairs and coordinator. Participants are selected solely on their availability, application essays, CVs, and LORs.) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________ Financial Assistance (Optional) If you are interested in applying for financial assistance to participate in this program, the following information is required and will remain confidential. Annual Household Gross Income: _____________ Number of Dependents: _____________ Does anyone in your household receive government assistance of any kind? (Unemployment Compensation, Social Security Benefits, Public Assistance, etc.) If yes, please state the amount that’s received annually: _________________________ Release Authorization Roswell Park Cancer Institute Elm & Carlton Streets Buffalo, NY 14263 *APPLICATION PAGE: RETURN TO ATLAS I authorize Roswell Park Cancer Institute (RPCI) to produce, use, disclose, display and/or reproduce, in color or otherwise, feature stories, articles, photographic portraits, pictures or videotapes of me, including still, single, multiple or moving, in which my voice, quotes by me, all or parts of my face or body appear (“the Photograph/Article”) and to modify, disclose or use a portion or portions of such Photograph/Article, alone or with any other photographic, audio, artistic or written information, including ________________________________, for the following purposes: To be used in Institute publications including but not limited to brochures, newsletters, magazines and websites and in other marketing materials including but not limited to_ newspaper and magazine articles, television and radio advertisements, and postings on internet and photo-sharing websites (e.g. flickr.com). I understand that I have a right to revoke this authorization at any time by presenting my written revocation to the Health Information Management Department. Unless otherwise revoked, this authorization will expire on the following date, event or condition: If I fail to specify an expiration date, event or condition, this authorization will expire in five years. I understand that authorizing the disclosure of this information is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment at RPCI. I understand that I may inspect or copy the written information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for re-disclosure and the information may then not be protected by Federal confidentiality rules. I acknowledge and agree that any photograph, videotape, publication and/or negatives and other descriptive material connected therewith created by RPCI pursuant to this Authorization shall be and remain the property of RPCI. RPCI will not receive compensation for using/disclosing information as authorized herein. If I have questions about disclosure of my health information, I may contact the Privacy Officer or the Health Information/Medical Record Department at 845-5990. Signature: ______________________________________ Date: ____________ Print Name: __________________________________ Parent/Guardian Signature: ______________________________ Date: ____________ Telephone Number: ____________________________________________ Mailing Address: _________________________________________________________ E-mail Address (optional): _________________________________________________ *APPLICATION PAGE: RETURN TO ATLAS Parental Acknowledgement, Consent, and Release Form: This section is to be completed and signed by the participant’s parent or legal guardian. If the student is 18 years of age or over they may complete and sign the form themselves. Please ensure that all of your documents are digitally submitted via email (AtlasTeam@RoswellPark.org) to Erinn Field or Allison Polakiewicz by 5:00pm on Friday January 9th 2015. The list of participants will be announced by March 6th, 2015. The Participant Pledge form is due by 5:00pm on April 3rd, 2015. This year’s program will run from June 22nd, 2015 to August 8th 2015 and is a 25+ hour in-program time commitment with 10+ hour outside-program time commitment. Participants must attend three sessions of a three hour devotion between 6/15/2015 and 8/1/2015, which will be assigned and sent out by March 6th 2015 as well as several dates in late July/early August. The cost for participation in this year’s program is $400. All spectators (friends, family, teachers, etc.) are encouraged to attend the JRSC Final Event on August 8th 2015 which will host the final competition with activities to cater to observers, a STEM career and technology fair, as well as the awards ceremony. I authorize my child (Full Name of Child), _________________________________________________________ to participate in the Junior Robotic Surgeon Challenge 2015. She/he attends (school) I certify that my son/daughter is in grade and is years old. Date of Birth: _________________ I have reviewed the materials attached to this 15 page document and will support my child’s commitment to this year’s program. I hereby release Roswell Park Cancer Institute and their respective member companies, affiliates, Board of Governors/Trustees, licensees and assigns from all claims, demands, liabilities, damages, costs and expenses that I may now or hereafter have against Roswell Park Cancer Institute arising in connection with this child’s participation in the Junior Robotic Surgeon Challenge. I hereby grant to Roswell Park Cancer Institute and their respective member companies, affiliates, Board of Governors/Trustees, licensees and assigns the right to photograph and/or videotape and use the videotape and/or photograph of the below named student during participation in any events related to the Junior Robotic Surgeon Challenge and the right to use this media without further compensation to me or the student or any limitation whatsoever. Parent/Guardian Name: __ ____ Signature: ________________________________________________________ Address: _______________________________________________________________________ City: Day Contact #: #: State: Zip: Evening Contact #: Mobile Email: Confirmation of Identity of Supervising Teacher: Teacher’s Name: _________________________________________ School Name: ________________________________________________________ School Address: _________________________________________________________________________ ___________ City: State: Zip: *APPLICATION PAGE: RETURN TO ATLAS (Returned by Teacher, only one form needed per school) Teacher Chaperone Information: Dear Teacher, You are invited to an information sharing event at Roswell Park’s ATLAS, leaving from the main hospital lobby by the information desk for the teacher tour and information session on 11/12/2014, 11/17/2014, 11/24/2014, or 12/8/2014 from 4pm-5pm, to launch the Junior Robotic Surgery Challenge 2015 program. Please register to attend by contacting Erinn Field at 845-8227 or AtlasTeam@RoswellPark.org. Perhaps among your student body there are individuals who are motivated, dexterous and focused, with an interest in a career in the field of Robotic Surgery. If you believe you have students capable of accepting this challenge please indicate your willingness to be their chaperone by filling out the information below. You are welcome to be acting chaperone of up to 6-participants indicated by the inclusion of a complete list of students that you will be supervising on the form below you will only have to submit this form once. There are very minimal requirements by our program for chaperones (whatever your school will require). Please ensure that the application portfolio is submitted via email (AtlasTeam@RoswellPark.org) to Erinn Field or Allison Polakiewicz by 5:00pm on Friday January 9th 2015. The list of participants will be announced by March 6th, 2015. The Participant Pledge form is due by 5:00pm on April 3rd, 2015. This year’s program will run from June 22nd, 2015 to August 8th 2015and is a 25+ hour in-program time commitment with 10+ hour outside-program time commitment. All participants must attend three+, three hour sessions between 6/15/2015 and 8/1/2015 which will be assigned and sent out by March 6th 2015 as well as several dates in late July/early August. All spectators (friends, family, teachers, etc.) are encouraged to attend the JRSC Final Event on August 8th 2015 which will host the final competition with activities to cater to observers, a STEM career and technology fair, as well as the awards ceremony. Yours sincerely, Eilene O’Brien, PhD Immaculate Conception School Co-Chair, Junior Robotic Surgeon Competition Competition Khurshid Guru, MD RPCI, Director of Robotic Surgery Co-Chair Junior Robotic Surgeon First Name: Last Name: Phone Number: (with area code): Primary Email: ______________________________________________________________ Signature: ________________________________________________________________ ______ By signing the line above you are indicating that you have read/reviewed the 11-page application, fully understand its content and the expected requirements of participants and are committed to acting as the sole supervisor to the students from your high school interested in participating in this program, taking into account the requirements of your institution. Interested in being more active in the program? Please indicate the extent to which below (Observation/direct supervision, grader/judge in main event, volunteer on OR robot day, etc.)… _________________________________________________________________________ _________________________________________________________________________ __________ Names of the students you agree to supervise for this program (Note: Only 6 students may be nominated to apply to JRSC per school): Last Name: __________________________ First Name: ________________________________ Last Name: __________________________ First Name: ________________________________ Last Name: __________________________ First Name: ________________________________ Last Name: __________________________ First Name: ________________________________ Last Name: __________________________ First Name: ________________________________ Last Name: __________________________ First Name: ________________________________ APPLICATION PORTFOLIO CHECKLIST: i. Current Curriculum Vitae (Guidelines on pg. 3) ii. Two Letters of Recommendation(Guidelines on pg. 3) iii. Essay(Guidelines on pg. 3) iv. Participant Application Pages (pg. 5 & 6) v. RPCI Photo Release Form (pg. 7) vi. Parental Acknowledgement, Consent and Release Form (pg. 8 & 9) vii. Teacher Chaperone Information (pg. 10 & 11) Copyright © 2014 Roswell Park Cancer Institute, All rights reserved. Our mailing address is: Atlas.Team@RoswellPark.org