APPLICATION
FOR ADVANCED GENE MAPPING COURSE
April
22-26, 2024
The
Rockefeller University
New
York, NY
First name: _________________________Last
name: _______________________________________
Affiliation: _________________________________________________________________________
Address: _________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Phone number:
_________________________________________________________________________
E-mail:_______________________________________________________________________________
Applying for fellowship: __________Yes
__________No
Please attach a copy of your curriculum vitae and
a letter describing your experience with genetic epidemiology,
association studies, gene mapping of complex or Mendelian traits and/or
statistical genetics. If you are analyzing data for specific studies or
developing methods, please explain in your letter.
If you
are applying for a travel stipend, please also submit
a letter of recommendation from your advisor or department head.
Please tell us about your research interest (e.g., Cardiovascular diseases, Bipolar, Schizophrenia, Method development in statistical genetics). _________________________________________________________
If you are a trainee (pre-doctoral or post-doctoral) please provide
your advisor’s name ____________________________________________
and email
address________________________________________________________________________
Room
Sharing: Are you interested in sharing a
room with another course participant? ______ Yes_____ No
We
will supply you with a list of names and email addresses from other course
participants who are also interested in sharing a hotel room.
Are you a USA Citizen _______Yes ________No
If No are you a Permanent Resident (Green Card holder) ______yes _______No
Other type of visa _________yes ________no
If Yes type of visa ______________________________________________________
The NIH supports this course. They request that we provide the following information. It is appreciated if you would supply us with this optional information.
Gender: _____ Male ______ Female _______ Other
Primary Appointment: _____ Academics______ Government______ Industry
Status:
Faculty: ______Professor _____Associate Professor _____Assistant Professor ______Instructor___________ Other Title (please specify ___________)
Research/Staff Scientist: ________Senior _______ Associate ________Assistant _________ Other Title (please specify______________)
Research Technician: ________Senior _______ Mid-career ________Junior ______________Other Title (please specify ______________)
Trainee:_______Post-doctoral ________Pre-doctoral ___________Other (please specify______________ _______________________)
Degrees (please check all that apply): _____ MD _____ PhD _____ MS or MA _____ BS or BA _____Other (please specify __________________________________________)
Ethnic Background (please check all that apply): ____ American Indian or Alaskan Native _____Asian _____ Black _____ Pacific Islander _____ White
Hispanic: ________Yes ________No
Financially disadvantaged (as defined by https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines): ____Yes ____ No
Educationally disadvantaged background below high school level e.g., an inner-city public school: ____Yes ________No
Physically or mentally disabled: ________Yes ________No
If yes, please specify. Accommodations will
be made to aid you in attending the course
__________________________________________________________________________________________