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