2017 LEAPS into IM Application Form
LEAPS into IM is a week-long intensive integrative medicine experiential and leadership training. Participants have found that LEAPs transforms their leadership skills, self-care practice, and ability to work with interprofessional teams. This year, the program will be held from June 4-9, 2017 at the Old Mission San Luis Rey in Oceanside, CA.

Please note that the following information will be required in order to submit the application:

1. Personal statement.
2. Description of the proposed student project. (Please note, we anticipate the project may shift over time as we work through details during the on-site leadership training component of the program.)
3. Email address for the Dean of Students (or equivalent) at your school.
4. Name, phone number and email address of a mentor at your school who has agreed to help you execute your LEAPS project.
5. Letters of support from both the applicant's Mentor and Dean (to be turned in with the application).

The following individuals are encouraged to apply:

 Medical and Osteopathic Students, especially those who will have completed their first year of training.

 Pharmacy, Nursing, Allied Health students, especially those completing their first year of training.

 Health profession trainees, including but not limited to acupuncturists, chiropractors, naturopaths, and massage therapy students who have finished their first year of training.

 Note: Participation is not limited to first year students. However the level of training must be commensurate with the ability to complete the home institution project in a sustainable way.

If accepted, a check for the $500 program fee made out to the Consortium of Academic Health Centers for Integrative Medicine must be mailed in by March 30th, 2017.

PLEASE NOTE: applications will be reviewed on a first-come, first-serve basis, so submission in a timely manner is rewarded. The deadline for applying is February 15th, 2017.

Contact leaps.consortium@gmail.com for questions and additional information.

Full Name *
Your answer
Age *
Your answer
School *
Please write out full school name, no abbreviations.
Your answer
School Year *
For ex. MS1, MS2, ....
Your answer
Expected Graduation Date *
Your answer
Gender *
For Housing Purposes
Your answer
Mailing Address *
Include full street address, city, state and zip code
Your answer
Email Address *
Your answer
Confirm Email Address *
Your answer
Phone Number *
Including area code
Your answer
Are you currently an AMSA National member? *
Is your school a member of the Academic Consortium for Integrative Medicine & Health? *
Name of Dean of Students (or equivalent) at your school *
Your answer
Email address of the Dean of Students (or equivalent) at your school *
Participation in this program requires certification that you are in good academic standing and recommended for and are able to commit to the entire length of the program. We will be sending an email to your Dean for confirmation.
Your answer
Confirm Dean's email address *
Your answer
Name of a mentor at your school, who has agreed to support you in executing your LEAPS project *
Your answer
Email of your Mentor *
Participation in this program requires a letter of recommendation from your mentor in support of your proposed project. We will be sending an email to your mentor requesting this letter.
Your answer
Confirm Mentor's email address *
Your answer
How did you hear about LEAPS into IM? *
Required
List past/present relevant work experience *
Your answer
List past/present relevant volunteer work *
Your answer
List relevant past/current leadership positions and club memberships at your school *
Your answer
Does your school have a required Integrative Medicine course or an elective Integrative Medicine course? If so, please describe. *
Your answer
Does your school have an Integrative Medicine Interest Group or equivalent? Who is that Group’s faculty advisor? *
Your answer
Personal Statement (500 word maximum) *
Describe your interest and experience in integrative medicine. Please discuss relevant leadership experiences and how the skills and knowledge gained from those experiences will help you to contribute to this program. Please also tell us what you hope to gain by participating.
Your answer
Gratitude Exercise (250 word max) *
Write a thank you letter to any person/place/thing/concept of your choice
Your answer
Proposed Project Description (250 words maximum) *
Project is preferred to be reproducible, sustainable, and professional-school-based. We prefer projects that will directly impact the integrative medicine curriculum at your school by creating or growing interprofessional integrative medicine interest groups at your institution. Project ideas may also be refined during the LEAPS experience.
Your answer
Agreement of Terms
Please check each box below to indicate understanding and acceptance of each item. Should you have any questions, please contact leaps.consortium@gmail.com BEFORE submitting your application.
I understand that, if accepted, I will be responsible for arranging my own travel, with expenses paid by my medical school and/or myself. I understand that the program will require my full attention and I will be required to commit to the entire duration of the program and stay in the housing provided. I agree to develop and execute an educational project upon returning to my medical school, a requirement for participating in the program. In addition, if accepted, all participants will be required to bring their own yoga mat and yoga supplies as they need (no prior experience with yoga is required). *
Required
I also understand that my involvement with this leadership program will extend beyond the program dates and I commit to continued communication about the progress of my project as well as my professional achievements and growth throughout my medical education career. I understand that I agree to writing a summary report with photos of my project. *
Required
By registering for and/or attending this training opportunity facilitated by the Academic Consortium for Integrative Medicine & Health in association with AMSA or the AMSA Foundation, I understand that I may be photographed or recorded by the above agencies. I understand that I can request that my image and name NOT be used by AMSA, the AMSA Foundation, or a partnering organization by submitting a request in writing to leaps.consortium@gmail.com before the training begins, or by providing a written request to the student coordinator on the first day of the training. If I do not submit a request in writing, I understand that AMSA, the AMSA Foundation, and their partnering organizations may use my image and name in future marketing, advertising, and promotional materials, including over the internet. Should you have any questions about this, please contact leaps.consortium@gmail.com . *
Required
I understand that I will be required to complete intermittent surveys tracking the effects of LEAPS into IM throughout my medical school training. *
Required
The mentor and colleague(s) I have identified and provided email addresses for have agreed to participate and/or complete surveys over time. *
Required
Your Dean will need to provide verification of your good academic standing and eligibility to participate in this program. The Dean’s letter should also state the support of the institution regarding your project. Your Mentor will need to provide a letter of recommendation in support of your proposed project. It is your final responsibility to ensure that your dean and mentor have provided the necessary verification and recommendation. Without this, your application will not be considered complete. By submitting this application for LEAPS into IM, you certify that all information is complete and accurate. By clicking submit, this acts as your electronic signature for this application. *
Required
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