2020 Combining Clinical and Research Careers in Neuroscience Application
The Combining Clinical and Research Careers in Neuroscience Symposium will be held June 12-13, 2020 at the National Institutes of Health in Washing, DC.

DEADLINE FOR SUBMISSION: April 1, 2020

Equity and inclusion are key to our vision to become innovative leaders in discovery, education, and care. Women, minorities, and people with disabilities are strongly encouraged to apply.

Questions pertaining to the application should be sent to Tracey White at tracey.white@emory.edu.

* This symposium is only available to students currently studying medicine in the U.S. or U.S. Territories.
SECTION 1: Applicant Information
First Name *
Your answer
Last Name *
Your answer
Preferred Name (if different than 1st name)
Your answer
Date of Birth *
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Name of Current Medical School (Please spell out completely) *
Your answer
Department or Program (if in MD/PhD program)
Your answer
City of Current Medical School *
Your answer
State *
Region of the U. S. where your medical school is located *
Contact Information
It is vital that you keep us informed about your career development by completing occasional brief surveys. Your personal email will be the primary address used for communication following the course.
Phone Number *
Your answer
Email Provided by University *
Your answer
Personal Email *
Your answer
Diversity, Equity, Inclusion, and Representation
Equity and inclusion are key to our vision to become innovative leaders in discovery, education, and care.
Gender *
Self Identification *
Required
Do you have a disability you'd like to make us aware of? *
If yes, please explain.
Your answer
What type of accomodation will you need?
Your answer
Special Dietary Requirement (select below) *
Required
Please list any food allergies you have. If you don't have any allergies, leave blank.
Your answer
Have you previously attended a CCRC Course? *
If you have previously attended a CCRC course, please select which year.
SECTION 2: Degrees
Date you entered medical school *
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DD
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YYYY
Anticipated graduation date from medical school *
MM
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DD
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YYYY
Current Degree(s) - Select all that apply. *
Required
Anticipated Degree(s) - Select all that apply. *
Required
SECTION 3: Clinical and Research Experience
Clerkships you have completed - Select all that apply. *
Required
Select the amount of research experience completed PRIOR to medical school. *
Select the amount of medical school research you have completed. *
What clinical specialty(ies) are you contemplating? Select all that apply. *
Required
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