Fellowship Application

Only one summer project fellowship is awarded per student (Either a research fellowship OR a global health fellowship)

*Class of:

*Fellowship Type:

Are you receiving funding from the Office of Medical Student Research?

*First Name:

*Last Name:


*Mobile Phone:

*Mailing Address:

Apt. #:



*Zip Code:



*Banner ID:

*Date of Birth:

*Proposed Subject Project:

*Facility Where it will be Conducted:

*Name/Title of Mentor at Einstein:

*Name/Title/Contact Information of Sponsor Abroad:

*Date of Travel (Start):

*Date of Travel (End):

*Have You Worked Internationally Before?

*Please Give Details:

*Your Travel Document Is:

*Passport Number:

*Passport Expiration Date:

*Designate Country:

*Designate Originating Country:

Award of a summer fellowship requires your signed agreement to the following:

For Medical Spanish, CFHI, Project Peru or Amazon Promise program, attach letter of acceptance. For all other programs, an e-mail of acceptance from the person with whom you will be working or person in charge of the program should be sent to jill.raufman@einsteinmed.edu.

Senior GH Fellowship
A minimum two-month stay is required for fellowship support given during the fourth year. If the global health program includes training in Medical Spanish, this must be done in addition to the two-month stay.

*Courses, international, and other experiences relevant to the proposed study:

*List activities at Einstein that provide evidence of your interest in global health, e.g., membership in student organizations, attendance at extracurricular global health conferences or lectures:

Project information: On separate pages, provide (1) description of proposed project details; (2) description of your career goals and relevance of project to them; (3) detailed budget.

Sponsor information: Submit letters from both sponsors. Letter from host institution sponsor should indicate your acceptance into proposed program and willingness to act as your mentor or supervisor. Letter from Einstein sponsor should indicate that he/she supports your application and has confidence in your ability to carry out the proposed project.

*Are You Requesting Additional Global Health Funds?

Students can be provided with additional funding if there documented financial need. If there is a need for further funding then this portion of the Global Health Fellowship application needs to be completed and submitted. No supplemental funds will be awarded without this financial need information.

*Have You Completed a FAFSA (Federal Application for Financial Aid) for the Current School Year?

*Did You Receive an Einstein Grant or Einstein Loan for the Current School Year?