APPLICATION FOR THE MINORITY ADVANCED CAREERS IN NURSING (MACaN)
2012 Summer Research Internship at PENN STATE SCHOOL OF NURSING
JUNE 4 - JULY 13, 2012
Completed applications are to be RECEIVED in our office by March 19, 2012. Mail the completed application to:
Staja Booker, RN, BSN, MS(c), MACaN Co-Coordinator
Minority Advanced Careers in Nursing
The Pennsylvania State University
School of Nursing
201 Health and Human Development East
University Park, PA 16802-6501
Please type OR print legibly in BLUE ink.
I. BACKGROUND INFORMATION
Name
Last Name
First Name
M.I.
Dorm or off-Campus mailing address
City
State
Zip _______________ Dorm or off-Campus phone (
State
Zip _______________ Home Phone (
)______________
Home mailing address
City
)_________________________
Ethnicity/Race (check all that apply):
Date of Birth (month/day/year)
Male
/
African American/Black American
Hispanic (Puerto Rican, Chicano, etc.)
Asian American
Native American/Alaskan Native
White (not Hispanic)
Other (please specify)
/
Female
________
________
________
________
________
_____________________
*****(VERY IMPORTANT)***** COMPLETE ALL THAT ARE APPLICABLE
Country of Citizenship
Visa Type
E-Mail
Name of undergraduate college/university
Address of college/university
Major
Minor_____________________________
Cumulative Grade Point Average
Expected date of graduation (month and year) __________/___________
Date Spring 2012 semester ends _______/________/________
What are your Clinical Nursing interests? (Check all that apply below)
Clinical: ___Med-surg ___Critical Care
___Peds/L &D
___Geriatric Care
___Psych/Mental Health ____________Other (indicate)
What type of Research you would like to be involved with this summer:
Research experience:
Do you have any experience working in a laboratory setting?
Are you willing to work with animals?
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List the professional and civic/social organizations of which you are a member and any positions of responsibility held:
II.
TRANSCRIPT
An official copy of your transcript should accompany this application.
III.
SHORT ESSAY
Please include a personal statement about your career goals and courses completed to date (max limit 2pgs)
IV.
RECOMMENDATION OF ADVISOR, FACULTY MEMBER, OR DEAN/DIRECTOR/CHAIR
Please ask a faculty member who is familiar with your work to provide a letter of recommendation.
TO THE FACULTY MEMBER:
1.
2.
Please indicate why you think the applicant would be a good candidate for our MACaN Summer Research Internship at Penn
State (e.g. describe the applicant’s professional and moral character as a student nurse, human individual, and future advanced
practice nurse [clinician, leader, scientist, and/or academician]; research ability or experience; written & verbal
communication skills; perseverance of goal pursuit, self-reliance, independence, and clinical proficiency, etc.). Please place
recommendation on an official letterhead in sealed envelope (max limit 2pgs).
Complete the section below.
Please indicate position:
Academic Nursing Advisor
Faculty Member
_____ Dean, Director, or Chair
(Please make sure your name is legible,
and your department and university are
included, especially if sending separately
from application, as copies of letters will
be mailed to you, as the recommender.)
FACULTY SIGNATURE:
DEPARTMENT, UNIVERSITY AND ADDRESS:
FACULTY NAME: (PLEASE PRINT)
PHONE:(
)
V. APPLICATION CHECKLIST
______ Completed Application
______ Personal Statement
______ 1 set of Official University Transcripts
______ 1 Letter of Recommendation
______ Resumé (OPTIONAL)
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FYI for Applicants
*(keep this page for your reference)
You may want to keep a copy of all completed forms for your records.
Applicants will be notified of acceptance by early April with an official letter. Upon receipt of letter, you will be
asked to ACCEPT or DECLINE the invitation. Deadline for acceptance or declination will be specified in the
official letter.
Your letter may also state the name and contact information of your appointed advisor for the summer experience,
and an emergency contact form to complete for our records will also be enclosed.
MACaN Contacts:
Staja “STAR” Booker, RN, BSN, MS(c), MACaN Co-Coordinator
sqb5261@psu.edu
201 Health and Human Development East
The Pennsylvania State University
University Park, PA 16802
Office: 814-863-0776
Fax: 814-863- 2925
Lisa Kitko, PhD, RN, CCRN, MACaN Coordinator
lah150@psu.edu
307D Health and Human Development East
The Pennsylvania State University
University Park, PA 16802
Office: 814-863-2228
Fax: 814-863-2925
Penn State School of Nursing website: http://www.nursing.psu.edu/about/
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