The Jonas Salk
Fellowship
A program of
the Jewish Healthcare Foundation
and
Health Careers Futures
When:
The 2012 - 2013 Jonas Salk Fellowship will meet monthly on the following Tuesdays:
Oct. 16, Nov. 6, Dec. 4, 2012 AND Jan. 8, Feb.5, 2013
Meetings are always 4:30 p.m. to 7:30 p.m. (Dinner is provided)
Where: Downtown Pittsburgh (Centre City Tower)
Who can apply: Current or recent students in health-related graduate programs (including but not limited
to: Medicine, Physician Assistant, Nursing, Pharmacy, Dentistry, Occupational and Physical Therapy, Speech
Pathology, Health Law, Health Policy, and Public Health).
* Up to 25 applicants are accepted
How to apply: Complete the attached application or visit www.hcfutures.org for an electronic version of
the application.
***** Application deadline is September 18, 2012*****
Return the application and attachments via mail to:
Michelle Anderson, MOT, OTR/L
Program Manager
Jewish Healthcare Foundation
Centre City Tower
650 Smithfield Street, Suite 2400
Pittsburgh, PA 15222
Or via email to: anderson@jhf.org
For More Information:
Contact Michelle Anderson at 412-594-2581 or anderson@jhf.org
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The Jonas Salk
Fellowship
NAME: Click here to enter text.
CURRENT ADDRESS: Click here to enter text.
EMAIL*: Click here to enter text.
PERMANENT ADDRESS: Click here to enter text.
PERMANENT PHONE NUMBER: Click here to enter text.
PERMANENT EMAIL*: Click here to enter text.
CURRENT COLLEGE/UNIVERSITY: Click here to enter text.
YEARS COMPLETED: Click here to enter text.
EXPECTED GRADUATION DATE: Click here to enter text.
CURRENT DEGREE PROGRAM: Click here to enter text.
MAJOR(S) OR AREA OF FOCUS: Click here to enter text.
OTHER EDUCATIONAL INSTITUTIONS (DATES, MAJORS, DEGREES): Click here to enter text.
HOW DID YOU LEARN ABOUT THIS FELLOWSHIP? Click here to enter text.
HAVE YOU PREVIOUSLY APPLIED FOR A JHF FELLOWSHIP?
☐ YES
☐ NO
IF YES, PLEASE LIST WHICH FELLOWSHIP(S): Click here to enter text.
* Email is the primary means of communication between the Jewish Healthcare Foundation, program applicants,
Fellows and Fellowship alumni.
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The Jonas Salk
Fellowship
APPEARANCE CONSENT AND RELEASE
I, the undersigned, in exchange for good and valuable consideration, and without further consideration, do
hereby irrevocably grant the JEWISH HEALTHCARE FOUNDATION (JHF), its parent, affiliates, subsidiaries,
licensees, successors, nominees, agents, assigns, and those for whom it is acting my consent and the
unrestricted right and permission to copy, publish, republish, edit, record, reproduce, broadcast,
rebroadcast, distribute, transmit, exhibit, copyright, sell, merchandise, disseminate, use or otherwise
exploit, either in whole or in part, in any way throughout the universe and in perpetuity the audio and/or
visual portions of any videotape, film, pictures, negatives, prints, stills, promotional materials or other
recordings of me made in connection with the JEWISH HEALTHCARE FOUNDATION (JHF) and any
reproduction thereof, for use through any medium or media now known or hereafter devised including, but
not limited to, newspaper, home video release (whether by cassette, laser disc or other means), television
(whether by free, pay, pay-per-view, cable, broadcast, video on demand, near video on demand,
interactive, satellite or community), the internet, webcast, CD-Rom and other interactive means. I
understand and agree that the photographs, films, videotapes, pictures, negatives, prints, stills,
promotional materials or other recordings of me may be used with or without identifying me as their
subject. Such right and permission shall be exercisable, in whole or in part, at the sole discretion of JEWISH
HEALTHCARE FOUNDATION (JHF), its parent, affiliates, subsidiaries, licensees, successors, nominees,
assigns, or agents.
I understand that any statements and any reference to me in the photographs, films, videotapes, pictures,
negatives, prints, stills, promotional materials or other recordings of me may be used in connection with
the promotion of JEWISH HEALTHCARE FOUNDATION (JHF), in any of its fund-raising campaigns or by any of
its clients.
I hereby waive any right that I may have to inspect or approve any finished product, derivative thereof, or
the use to which such finished product may be applied.
I hereby release, discharge and agree to hold harmless JEWISH HEALTHCARE FOUNDATION (JHF), its parent,
affiliates, subsidiaries, licensees, successors, assigns and agents and those from whom it is acting, from any
liability, claim, or cause of action, now known or later discovered, including without limitation, liability for
libel, invasion of any right of privacy or publicity, and defamation arising out of the use of any photographs,
films, videotapes, negatives, prints, stills or other recording of me, or reference to me, or of any scene or
sequence in which my likeness or such reference appears.
I hereby warrant that I am age 18 or older. I acknowledge that I have read and understand this Consent
and Release prior to signing it and agree to the terms herein.
 Print Name: Click here to enter text.
 Signature: Click here to enter text.
(electronic signature will suffice)
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Date: Click here to enter text.
The Jonas Salk
Fellowship
APPLICATION SUBMISSION CHECKLIST
Please submit the following with your completed application and photo release:
PERSONAL STATEMENT: Include your expected contribution and gains from the
Fellowship. Explain how developing your leadership abilities relate to your career goals, interests, and
potential. DO NOT EXCEED 500 WORDS.
CURRENT RESUME: Include paid and volunteer positions, special skills, honors and
awards, campus activities, and community activities.
ONE LETTER OF RECOMMENDATION: Recommendation from a current or recent professor or
employer who is familiar with your character, academic abilities and accomplishments.
Return the application and attachments via mail to:
Michelle Anderson, MOT, OTR/L
Program Manager
Jewish Healthcare Foundation
Centre City Tower
650 Smithfield Street, Suite 2400
Pittsburgh, PA 15222
Or via email to: anderson@jhf.org
*** Application deadline is TUESDAY, September 18, 2012 ***
Applicants will be notified of the selection committee’s decision by TUESDAY OCTOBER 2, 2012.
If you are selected, please confirm your participation by FRIDAY, OCTOBER 5, 2011.
OUTREACH AND RECRUITMENT
While providing JHF with the following information is voluntary, it is important to us that we are successful in our efforts to reach
out to a diverse applicant pool. We would appreciate your cooperation in providing the following demographic information to
help gauge the success of these efforts.
DATE OF BIRTH: Click here to enter text. HOMETOWN, STATE/COUNTRY: Click here to enter text.
GENDER: Click here to enter text.
RACE/ETHNICITY: Click here to enter text.
DECLARATION ON APPLYING
In submitting this application, you affirm that you have read this complete application; that, to the best of your belief and
knowledge, the information you have given is true and accurate; and that if you are accepted as a JHF Jonas Salk Fellow and
decide to enroll in the program, you will complete the program in its entirety. *More than one absence or consistent tardiness
to the Fellowship may cause dismissal from the program.* You further commit to respect confidences shared on assignments
and throughout the JHF Jonas Salk Fellowship. Your signature below affirms your declaration on applying.
Click here to enter text.
Click here to enter text.
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YOUR NAME (PRINTED)
YOUR SIGNATURE (ELECTRONIC SIGNATURE WILL SUFFICE)
DATE
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