Emergency Medicine Research Associate Program

Instructions:

For PC and MAC users: Please use Microsoft Word to fill out the electronic application. Once completed, please
save the application as Last Name, First Name, Quarter, Year.doc (ex. Smith, John, Summer 2011.doc) and email it with the subject titled Quarter Year Application (ex. Fall 2011 Application) to the Chief RA at EMRAPChiefRA@gmail.com

APPLICATION DEADLINE: September 6th, 11:59pm

Class Requirements Attend ICC Confirmation Meeting (9/21/11 Time: 2-3:30pm) UCDMC Volunteer Services Orientation UCDMC EMRAP Orientation: UC Davis Medical Center Campus Mandatory weekly (MONDAY 3-5pm) lectures at the UCD Medical Center (2hrs/wk) Give one 10 minute presentation on a medically related topic and pass one final on research study protocols and weekly lectures A minimum of 4hrs/week in the Emergency Room for the duration of the quarter. (In addition to mandatory weekly lectures)

Please submit your application via email to Chief RA at EMRAPChiefRA@gmail.com. If you are a UC Davis student or an affiliate, you MUST submit the application through a UC Davis e-mail account for verification. If you are not a UC Davis student or affiliate, you may submit your application through Gmail, Hotmail, etc.

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EMRAP Application Please fill out the grey boxes and email the completed application as a Word attachment to the Chief RA at EMRAPChiefRA@gmail.com. This application must be complete for consideration.
Name:

Select one

(Last)

(First)

(Middle)

Address:

(Number & Street)

(City)

(State)

(Zip)

Telephone:

() -
(Home)

() -
(Cell)

(Email Address)

Please check all that apply. I am currently a non-UC Davis student. I am currently a registered UC Davis student. I am currently not a student.
School

I am not/do not plan on registering at UC Davis next quarter. I plan on staying in Davis during the summer. I am transferring to UCD during the next academic year
GPA (*cumulative)

Major/ Minor

Select one
Class Standing

Anticipated Date of Graduation (Month, Year) Your Plans for a Health Care Career (5 lines max)

Select one
Anticipated EMRAP Commitment

Prior Healthcare Field Experience (List experience(s), date(s) of participation, and one line description)

Prior Community Volunteer Experience (List experience(s), date(s) of participation, and one line description)

Prior Research Experience (List experience(s), date(s) of participation, and one line description)

Prior Work Experience (List experience(s), date(s) of participation, and one line description)

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Personal Statements: Please answer both essay prompts within the specified frames.
Use the space below to explain why you would like to participate in EMRAP and what you hope to get out of EMRAP (450 words max)

Explain prior experiences or training that you have that can be useful in EMRAP (450 words max)

Reference Information (non-student)

Name

Relation (boss, supervisor, etc)

() -
Telephone

Organization/ Company

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* Please use the cumulative GPA listed as Overall on your Final Grades in SisWeb. If you recently transferred to UCD and do not have grades for UCD, please list the GPA(s) obtained at your previous institution(s) of learning.

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