Exit 2019 RREMS Student Application Question Title * 1. Please provide the following information: Name of Student (First and Last): * Student's Medical School: * Student's Mailing Address: * City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Student Contact Email: * Student Contact Phone: * Question Title * 2. Year in Medical School: MS1 MS2 MS3 MS4 Question Title * 3. Proposed Mentor Information Mentor Name Institution Mentor Email Question Title * 4. Title of Proposal Question Title * 5. Please submit all requested materials saved together as a single PDF file. Must include your Research Plan, CV or Resume, and NIH Bio-sketch for your faculty mentor. The following optional materials may also be included, a one-page Personal Statement and up to two Letters of Reference. PDF file types only. Choose File Choose File No file chosen Remove File Please submit all requested materials saved together as a single PDF file. Must include your Research Plan, CV or Resume, and NIH Bio-sketch for your faculty mentor. The following optional materials may also be included, a one-page Personal Statement and up to two Letters of Reference. Question Title * 6. Please complete the following information about the availability of PM&R programs at your medical school. Select all that apply. There is a PM&R Department There is a PM&R Residency Program There is a mandatory PM&R clerkship None of the above Comments: Question Title * 7. Gender M F Question Title * 8. Ethnicity Hispanic or Latino Not Hispanic or Latino Question Title * 9. Race American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other/Mixed Question Title * 10. Disability Question Title * 11. Any special accommodations needed? Yes No If yes, please explain: Question Title * 12. How did you find out about the MSSCE program? Select all that apply. AAP Website AAP Newsletter AAP eBrief PM&R SIG Classmate/Resident Medical Association (Other than AAP) Other (please specify) Done
