Pediatric Student Research Program (PSRP) Application

Please complete all applicable fields and email Lori Maloney at psrp@kids.wustl.edu with any questions.
I. Applicant Information
Applicant Name:
First Name
Your answer
Last Name
Your answer
Middle Name
Your answer
Preferred Name:
Your answer
Email Address
(This email address will be used to contact you regarding the status of your application).
Your answer
II. Education
A. High School
(Name of high school currently attending or attended)
Your answer
High School Address
(number and street)
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Cumulative GPA
Your answer
Enrollment Status
B. College (Undergraduate)
*High school applicants; please provide anticipated college enrollment if applicable.
Your answer
College Location
City
Your answer
State
Your answer
Zip Code
Your answer
Degree/Major Area of Study
Your answer
Cumulative GPA
Your answer
Enrollment Status
C. College (Graduate; if applicable)
Your answer
College Location
City
Your answer
State
Your answer
Zip Code
Your answer
Degree/Major Area of Study
Your answer
Cumulative GPA
Your answer
Anticipated Degree Completion Date
MM
/
DD
/
YYYY
III.Individual Providing Letter of Recommendation
This reference must be a science teacher, professor, work supervisor, academic advisor, or sponsor an activity or club in which the applicant participated. It is the responsibility of the applicant to verify that the reference has submitted a letter.

Do not request more than one letter of recommendation to be submitted in support of your application.

Name:
First
Your answer
Last
Your answer
Credentials (ie; PhD)
Your answer
Professional Title:
(ie; Professor of Pediatrics)
Your answer
Place of Employment:
Your answer
Phone Number:
Your answer
Email Address
Your answer
IV. Activities and Employment
Please list no more than five extracurricular activities (research, school, community, religious, athletics, personal, science or math competitions), employment experience, programs, or projects outside of regular class work you have been involved in during high school and/or college.
A. Name of Activity or Place of Employment:
Your answer
Years of Participation:
Your answer
Recognitions or Positions Held:
Your answer
B. Name of Activity or Place of Employment:
Your answer
Years of Participation:
Your answer
Recognitions or Positions Held:
Your answer
C. Name of Activity or Place of Employment:
Your answer
Years of Participation:
Your answer
Recognitions or Positions Held:
Your answer
D. Name of Activity or Place of Employment:
Your answer
Years of Participation:
Your answer
Recognitions or Positions Held:
Your answer
E. Name of Activity or Place of Employment:
Your answer
Years of Participation:
Your answer
Recognitions or Positions Held:
Your answer
V. Goals and Interests
A. Please list any immediate and long-term career goals you may have:
Do not exceed 1,500 Characters; Approximately 250 Words
Your answer
B. List any honors, awards, or recognitions you have received:
Do not exceed 1,500 Characters; Approximately 250 Words
Your answer
C. Why do you want to conduct research this summer and what do you hope to gain from your experience?
Do not exceed 1,500 Characters; Approximately 250 Words
Your answer
D. Research Interests (check all that apply):
Examples of Basic Lab Research would be: 1) Studying how the liver regenerates after injury in an animal model 2) Investigating how genetic mutations might lead to cancer 3) Studying how the immune system helps to control a viral infection. Examples of Patient-Oriented Research would be: 1) Studying how antibiotic-resistant bacterial infection is acquired 2) Studying risk factors that lead to the development of asthma 3) Investigating the best way to treat patients with brain injury
Specific Areas of Interest
Rank based on interest (1=most interest); choose at least 3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Cancer
Cardiology/Heart Defects 
Community outreach/education
Development/Birth Defects 
Endocrine system/Diabetes
Epidemiology
Gastrointestinal system
Genetics
Immunology/autoimmunity
Kidney disease
Metabolism/Nutrition
Microbiology/Infectious Diseases
Neuroscience/Brain injury
Respiratory system/Asthma
E. How did you learn about the PSRP?
Your answer
F. Have you been in any contact with a current Washington University Pediatrics faculty member that you would be interested in working with? If so, please provide name.
Name of Faculty Member
Your answer
Review Application Prior to Submission
Before submitting the electronic application please review the application for accuracy as the Acknowledgement Form that is uploaded will certify that the information included in the application is correct. If under the age of 18, please also have the parent or guardian that is signing the form review.
I certify that I have reviewed the application for accuracy and if under the age of 18 have also reviewed with a parent or guardian.
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