Family and Social Medicine

MonteHOP Student Application

Application submission deadline: April 9, 2021 Program Dates: July 6, 2021 through July 29, 2021

Instructions: Please complete all sections. All information will be kept confidential. Two letters of recommendation are required.

Eligibility: This program is particularly tailored to promote the recruitment of persons from disadvantaged and underrepresented backgrounds into health care careers.

A sample schedule can be seen here.

A sample of the medical form can be seen here.

Summer Internship Program Information

Please read application package in its entirety.

Program Description: The Montefiore Health Opportunities Program is a stipend funded summer enrichment program for students from economically or educationally disadvantaged backgrounds and/or from groups typically considered underrepresented in the healthcare fields. The goal of the program is to promote, educate and encourage youth to pursue careers within healthcare. This program has been in existence since 2002 and has graduated over 180 students. Students will gain valuable knowledge and professional skills through interactive workshops, mentorship by health care professionals, observation of health care professional-patient interactions, lecture activities, formal presentations and independent learning.

Eligibility Criteria (must be):

Graduating High School Senior or College Freshman/Sophomore
A U.S. citizen or a Permanent Resident
From a group considered economically or educationally disadvantaged and/or from groups considered underrepresented in the health fields
Commit to participate in all activities of the program on a daily basis
(absences and lateness are not acceptable)
Formal program dates: July 6, 2021 through July 29, 2021

Tuesdays, Wednesdays, and Thursdays, 9 - 1PM (with some afternoon sessions TBD)

Interviews via zoom will be scheduled in April- May 2021

We highly encourage students to upload all materials to complete their application package as soon as possible. Students who complete their applications in a timely fashion are more likely to receive an interview. Please note an interview does not guarantee acceptance. Thank you.

Contact information:

Jenna Scholnick, MD
Director
Montefiore Health Opportunities Program (MonteHOP)
Department of Family & Social Medicine, 2^nd Floor 3544 Jerome Avenue Bronx, N.Y. 10467

Any questions about the application process and or program please contact
Deyanira Acevedo
deaceved@montefiore.org
718-920-5521

Bedilia Jones
bedjones@montefiore.org
718-920-5521

Application Checklist

Name of Student	Date Completed
School Name	Preferred Phone Number

The following items MUST be completed and submitted prior to the application deadline. It is the responsibility of the applicant to ensure that all materials are received prior to the stated deadline.

Incomplete applications will not be reviewed.

1		Upload passport sized photos
2		Upload 1-2 Page Typed Essay
3		Upload Updated Resume
4		2 Letters of Recommendation (must be mailed in a sealed, signed envelope)
5		Signed Applicant Consent Form (must be signed by parent/guardian for students under 18 years of age and Uploaded)
6		Consent for News Media Participation (must be signed by parent/guardian for students under 18 years of age and Uploaded; must also be signed by all students)
7		Professionalism Contract (must be signed by parent/guardian and students for students under 18 years of age and Uploaded)
8		Upload School Transcript (can be non-official) (most recent showing at least last year’s courses/grades) *Grades are not an official consideration for acceptance but are used to assist accepted applicants during educational planning for those who are accepted.

General Information

Name:

Last Name

First Name

Middle Name

Date of Birth:

Upload a Professional Headshot Photo

Current Address:

Street
City
State
Zip Code

Home Phone:

Cell Phone:

E-Mail Address (list all separated by comma):

Last four digits of Social Security Number:

Gender:

Permanent Address:

Street
City
State
Zip Code

Languages Spoken:

Fluency:

Emergency Contact Information:

Name:

Relationship:

Phone:

Education

Name of School:		Expected Date of Graduation:
Current Year in School:	Graduating High School Senior	College Freshman	College Sophmore
School Address:	Street City State Zip Code
GPA (cumulative) or Average:		Major:	Minor:
** If Graduating H.S. Senior, what college are you going to?:
Are you a first generation student (first in your family completing high school or college): Yes No
Citizenship:	US:	Permanant Resident:
Ethnic Background: (Check all that apply)
African American:	Native American Indian:		Hispanic\Latino:
White:	Pacific Islander:	Other:
Other (Please Specify):
Economic: What is your household income (combined income of all persons working in home to support family)? This information is helpful in assessing which students qualify as economically disadvantaged and assists us in acquiring additional funds to continue student stipends: $
Professional Interests: What health career areas are you most interested in? (Please check all that apply)
Nursing:	Medical Doctor: Specialty:	Public Health:	Pharmacy:
Physical Therapy:	Biomedical Research:	Teaching:	Other (Please Specify):
Please list previous volunteer work and/or research experience: related to health care.
List any honors, awards or certifications:
List hobbies and/or special interests:
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):
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 anticipate any challenges with traveling independently? If yes, please describe?
*This program requires a 6 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
All students applying to college must confirm orientation dates for college prior to completion of application period and inform the program of those dates. There are often many options for dates for orientations. If you are truly interested in this program please work with your school to choose a date that doesn’t conflict with our program dates. Thank you.
Required essay: Please describe the following: 1) why you are interested in applying to this program; 2) what particular health field you are interested in, if any, and why; 3) and how you think your participation in this program will help you achieve your short and long term personal and professional goals. Please have your essay reviewed by a mentor or advisor and ensure essay is completed in a professional manner.(Minimum 2 page essay)

Evaluator Form

Applicant's Name:

Dear Evaluator,

This student has applied to the Monte-HOP Summer Internship. The Monte HOP internship provides students with an opportunity to explore various health careers through interaction with health professionals. Students also engage in professional skill building activities and learn about important health issues affecting the community. This letter must come from a person with whom the student has established a professional or educational relationship with, not from a family member/friend/or friend of the family.

Please return your recommendation in a sealed envelope. These recommendation letters are kept confidential. We students who would benefit the most from our program and who have the most serious interests in health care to be accepted. Thank you for your cooperation.

Evaluator’s Name:

Title & Relationship to Student:

School Agency or Organization:

Address:

Phone: Email Address:

Please answer the following questions about the applicant in your letter of recommendation:

Explain why you feel this student would benefit from this program?
In what ways does the student strive to meet his/her responsibilities?
How does this student stand out from other students?
Any particular concerns/reservations?

Please address recommendation letters to:
Jenna Scholnick, MD
Director

Letters should be emailed by evaluators to:
Email: deaceved@montefiore.org

Application Consent Form

Application Deadline April 9, 2021

I understand that only completed applications returned deadline, March 20, 2020 will be reviewed for consideration.


Please Sign Here:
Signature of Applicant	Date signed

I understand that there are limited internship positions available. I also understand that a completed application does not guarantee an interview and that an interview does not guarantee acceptance into the program.


Please Sign Here:
Signature of Applicant	Date signed

Program consent form: ALL students must sign one of the sections below (*Section B is for students in high school or under 18 years of age and requires parent/guardian signature).

Section A: Students 18 years and older

I, (Students Name) understand that if accepted into the program I will be expected to participate fully and professionally in various academic seminars, small group projects, hands on activities, observational shadowing activities in clinical environments, lectures and field trips, including but not limited to hospitals, health clinics and health professional schools. I also understand that I will be expected to travel independently by mass transit to various sites.

(Print) Students Name

Date

Please Sign Here:

(Signature) Student

CONSENT AND RELEASE FOR USE OF IMAGES

I, , hereby agree to grant to Montefiore Medical Center and Albert Einstein College of Medicine, 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, 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.
	Please Sign Here:
Name (PRINT):	Signature:
Address:		Date:
E-Mail Address (optional)		Phone:
If participant is a minor:
Relation:	Name:	DOB:

Professionalism Contract

I,, agree that, if accepted to participate in the program, I will abide by the following professional code of ethics:

To arrive on time to all activities and participate fully.
To contact the coordinator or program manager immediately in case of
To complete and submit high quality assignments in a timely fashion.
To conduct myself in a professional manner at all times, i.e. attire & demeanor/behavior.
To turn all electronic equipment off during the program (ie: phones, computers, beepers, etc…).
To fully adhere and comply with all HIPAA guidelines as it relates to patient confidentially.
To promptly notify the Program Director and Manager, as well as the program coordinators, of any issues that may limit my full participation in this learning
To enjoy, have fun and fully partake in all activities of the Montefiore Health Opportunities Program.

I,, verify that I have received and read the Montefiore Health Opportunities Program Manual. I agree to attend all planned sessions, five days of the week and to adhere to the dress code and expectations for professional behavior. I also agree to submit and present a well prepared public health project. I understand that if I am getting funded to participate in this program through a personal source (external funding) I will not receive stipend funding from Monte HOP. I further understand that I must complete the six week summer program satisfactorily (as detailed in above professional requirements) to receive the program stipend, if eligible. I am also aware that I may be dismissed from the program for non-compliance with above expectations or for missing 2 or more days from the program.

Student Name:

Date:

Please Sign Here:

Signature (Student):

Attachments

Upload Essay		Upload Resume
Upload Transcript

IF YOU WOULD LIKE TO SAVE YOUR WORK AND RETURN TO YOUR APPLICATION LATER:

Make sure that you have included your email on the General Information Tab above.
Click the “Save” button below. (the button will not be enabled until a valid email address has been supplied)
Once you click “Save,” an email will be sent to you with a link to get back into your application. Please note that once you hit “Submit,” you will no longer be able to get back into your application.

Centers of Excellence

Family and Social Medicine

MonteHOP Student Application

Summer Internship Program Information

Eligibility Criteria (must be):

Tuesdays, Wednesdays, and Thursdays, 9 - 1PM (with some afternoon sessions TBD)

Contact information:

Application Checklist

General Information

Education

Evaluator Form

Application Consent Form

Please Sign Here:

Please Sign Here:

Please Sign Here:

Please Sign Here:

Section B: Students under 18 years

Please Sign Here:

Please Sign Here:

*** Parent/Guardian signature required for those students under 18 years old

CONSENT AND RELEASE FOR USE OF IMAGES

Please Sign Here:

Professionalism Contract

Please Sign Here:

Please Sign Here:

*** Parent/Guardian signature required for those students under 18 years old

Attachments

IF YOU WOULD LIKE TO SAVE YOUR WORK AND RETURN TO YOUR APPLICATION LATER:

Please Sign Here: