Student Coordinator Application

Position Description

Position: Student Coordinator

Program Goal & Description:

This nine week summer program starts June 10, 2019 and runs until August 16, 2019. This is a summer enrichment program for ten to twelve minority senior high school and/ college freshman and sophomore students interested in pursuing careers in the health field. Program students will engage in general career development activities (writing resumes, mock interviews), receive lectures on health related topics, lectures on time management, and on stress management, learn about what it means to apply to graduate or medical school, engage in personal reflection activities, increase their repertoire of academic skills (via lectures in creating power points, creating and conducting research projects, performing basic literature searches) and participate in health related field trips around the city, In addition program students are required to present a major health related project at the end of the program.

Coordinator Job Description:

Coordinators will work in to mentor and oversee the program. The program runs five days a week Monday – Friday, 8am-5:00pm (a few sessions will run later)

During the first week coordinators will work closely with program leadership on administrative tasks; creating the six week program schedule, composing the teaching and mentoring activities, as well as doing outreach with physicians and other health professionals to request their participation. Thereafter student coordinators will run the day to day activities of the program, network directly with participating physicians, troubleshoot issues that arise with program leadership and collect evaluation data on all activities.

Formative evaluation of the program will occur on an ongoing basis through daily feedback forms and weekly self-reflection sessions, distributed and collected by coordinators. Summative feedback will occur at the end of the program through focus group activity, exit interviews and survey.

During the six weeks of the program coordinators will do the above and furthermore will participate in mentoring activities. A major component of the mentorship role involves advising program students on a weekly basis as they work on creating their health project. Student coordinators will also have an opportunity to establish mentorship roles with senior physicians associated with the summer program.

In addition, if students are interested, the program leadership will work towards linking student coordinators with program students to continue longitudinal mentorship roles, under the guidance of program leadership.

General Information

Name:	Last Name	First Name	Middle Name
Present Address:	Street City State Zip Code
Permanent Address:	Street City State Zip Code
Home Phone:		Cell Phone:
Best way to contact you:
E-Mail Address:
Sex: M F:	Date of Birth:		SSN:

Education

Undegraduate Institutions:
Degree:	Major:	Minor:
Date Finished Degree:		GPA:
Please explain any interruptions in your educational career:
Languages Spoken:		Fluency:

Additional Information

Emergency Contact Information:
Name:	Relationship:	Phone:
Citizenship:	US:	Permanant Resident:
Ethnic Background: (Check all that apply)
African American:	Native American:	Hispanic\Latino:
White:	Pacific Islander:
Other (Please Specify):
How will you be traveling to the program sites: (i.e.; bus, train, vehicle):
How long will it take for you to travel from your place of residence (where you'll be living during the program) to the two main program sites?
Montefiore Medical Center (111 East 210th Street, Bronx, NY, 10467) Time:
Albert Einstein College of Medicine (1300 Morris Park Avenue, Bronx, NY, 10461 Time:
Do you have any family members who work in healthcare? If so, who and in what position?
How did you hear about the program? (If from a specific person please name them):

Commitment

In your own words describe why you are interested in this position and why you would be the ideal candidate. Include information regarding prior teaching and/or mentoring experiences, as well as prior experience coordinating similar activities. (Prior experience is not required, but is pertinent to mention). Elaborate on what you know about health disparities and the importance of workforce diversity. Also describe what special qualities and characteristics you can bring to the program and how you can use your personal and professional skills and experiences to contribute to the program's success. Please also describe how participating in this program will assist you with your short and long term personal and professional goals. (1 to 2 pages)

List hobbies and/or special interests:

*This program requires a 10 week commitment. Are there any days during the program dates above that you anticipate you won't be able to participate? If yes, please explain

CONSENT AND RELEASE FOR USE OF IMAGES

I, , hereby agree to grant to Montefiore Medical Center and Albert Einstein College of Medicine of Yeshiva University, its successors and all persons acting under its permission or authority including, but not limited to, its employees and agents (collectively, "Montefiore and Einstein") permission to photograph, publish, reproduce, record and use photographs, motion pictures, videotapes or audio tapes (collectively referred to as "Images") of me (or my child, [INSERT NAME]), in order to memorialize the medical care, surgery, any other procedures to be performed, my presence at Montefiore and Einstein facilities, and/or participation at Montefiore and Einstein events. The Images may be used for any and all purposes, including but not limited to distribution to the media, educational, promotional, publicity, advertising and fundraising purposes, as well as for possible publication by Montefiore and Einstein in various traditional and social media (e.g. Facebook) and on the internet. I acknowledge and agree that neither Montefiore nor Einstein will pay me (or my child) in any manner for such photographing/ recording and use of the Images. I grant this permission and release as a voluntary contribution and I waive any and all rights I(or my child) may have to royalties or other compensation in connection with any such publication or use. I hereby waive my right to inspect and/or approve the finished products and final usages

I hereby release and discharge Montefiore and Einstein from any liability by virtue of any blurring, distortion, alteration, optical illusion or use in composite form that may occur or be produced in the creation or processing of any images created by Montefiore and Einstein. The foregoing permission is granted for the entire time period during which I (or my child) receive(s) outpatient and inpatient treatment at Montefiore or Einstein and the right to use the Images shall continue until such time that the footage, photographs and other images are no longer used by Montefiore or Einstein for educational, promotional, publicity, commercial and fundraising purposes. I also understand that I may contact my attending physician in writing to revoke future uses, but that my revocation will not affect disclosures of information that have already occurred. I understand that I am not required to sign this form authorizing the use of Images, and I may refuse to do so without any effect on my receipt of care at Montefiore

I hereby release Montefiore Medical Center and Albert Einstein College of Medicine of Yeshiva University, its trustees, officers, employees, physicians, agents and assigns from any and all legal liability that may arise from any of the foregoing and I waive any and all rights I (or my child) may have to royalties or other compensation in connection with any of the foregoing.

Name (PRINT):

Signature: _________________________

Address:

Date:

E-Mail Address (optional)

Phone:

If participant is a minor:

Relation:

Name:

DOB:

Witness:

Name:

Signature: ____________________

Date: