American Indian/Alaska Native Leadership Initiative on Cancer

Spirit of EAGLES American Indian/Alaska Native Leadership Initiative on Cancer American Indian and Alaska Native (AI/AN) populations have very high incidence rates for specific cancer sites and poor survival rates for most cancers. The AI/AN Leadership Initiative on Cancer addresses comprehensive tribal cancer control through partnerships with The Network for Cancer Control Research among AI/AN populations, tribes, multiple cancer centers, and non- profit organizations on health issues. This Initiative will assist tribes 1) to increase community awareness and understanding of cancer, 2) to provide training in cancer control research for AI/AN researchers, and 3) to improve native community channels to the National Cancer Institute (NCI) so that research can be specifically focused on issues that affect Native people.

AAIP Annual Meeting The Spirit of Eagles has recognized the importance of providing travel assistance to students who are preparing for careers in medicine and research. We see the AAIP Annual Meeting as a key opportunity for development and networking. The Spirit of EAGLES will provide up to $1000.00 for airfare / transportation, lodging, and registration costs.

1. PLEASE NOTE: In the event you qualify for a scholarship, you may be asked to share a room with another scholarship awardee. If you know of another student applying for a scholarship and would like to room with that person, please let us know his/her name:

2. PLEASE ALSO NOTE: If you are selected for a scholarship and need to arrange for a flight, you will be provided with a voucher number to use Mayo Clinic’s travel agency to avoid having to pay with a credit card and waiting for reimbursement. Hotel room and other transportation expenses will be reimbursed after the meeting as soon as detailed, itemized receipts are sent to Spirit of EAGLES.

Key Dates:  Application Deadline: Friday July 15, 2016  Decisions will be shared by: Thursday July 21, 2016  Flights must be booked by: Monday July 25, 2016 If you have questions/concerns, please contact: Marcy Averill Operations Director for Spirit of EAGLES American Indian/Alaska Native Initiative on Cancer Mayo Clinic – Charlton 6 (507) 266-3064 [email protected]

Please fill in (type or print) answers to all of the questions. Use N/A if not applicable to you. General Information:

Name: (Last) (First) (M.I.)

SSN:* Date of Birth: *Social Security Number is required* MM DD YYYY

Age: Sex: Female Male Other

Tribal Affiliation (if applicable):

Best telephone number to reach you at:

E-mail:

 Please check the box next to the address that you’d like us to mail your reimbursement to: Home Address:

Street

City State Zip Code College Address:

Street

City State Zip Code Education Information:

College Attending:

Year in College:

Pre-Med Program Medical School Graduate School Other List:

If you have taken the MCAT and/or GRE, please indicate your score(s) and the year the exam was taken: MCAT: Year: GRE: Year: If you have NOT taken the MCAT and/or GRE, please indicate your approximate SAT and/or ACT score(s) and the year the exam was taken: SAT: Year: ACT: Year: Please provide at least 1 paragraph per question below. If you have printed this application – or if you run out of room in the provided boxes, please attach a page with answers to the following questions.

A. Please describe your area(s) of academic and professional interest:

B. Please indicate if you will be presenting (poster, panel discussion, pre-admission workshop) at the meeting and list reasons why you feel you would be a good candidate to be selected for this opportunity:

C. Please describe what you hope to learn at this meeting and how you will apply it to your studies and/or professional endeavors: D. Please provide the following Attachments/Documents: 1) Copy of your latest unofficial transcript listing current overall GPA 2) Letter of Support from Academic personnel or supervisor from summer work program; can be from previous opportunity (travel, scholarship application, etc.) Description of Needs:

There will be a limited number of scholarships available which could cover all or part of your registration, hotel and travel. Scholarship amounts are up to $1000 per student. As you prepare your budget to list below, please note the following guidance:  The workshop’s full registration student fee is $250.  The hotel room rate is $219 per night - for double occupancy (if sharing, responsible for $109.50 per night). If the Meeting hotel is full, we will work with you to find alternative AAIP designated hotel lodging at a negotiated rate.  Airfare and/or mileage (at the IRS rate of $0.56 cents per mile) can be included for travel.

Please indicate your expected expenses, with consideration to the guidance provided above and provide comments where appropriate:

Travel ______Airfare ______Mileage ______Other

Lodging ______

Registration ______

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Total ______Scholarship Guidelines:

1. Participants will attend all scheduled Annual Meeting activities.

2. Participants will limit use of cellphones and other technology during sessions to emergencies only.

3. Participants will introduce themselves to the Spirit of EAGLES Principal Investigator, Judith Salmon Kaur, M.D., during the Meeting and will attend her presentation at the Meeting.

4. Participants will introduce themselves at the Spirit of EAGLES exhibit, where they will meet Dr. David Baines, previous AAIP Physician of the Year.

5. Participants agree that their application information can be shared with AAIP, so that students can be included on notifications for future opportunities.

6. Participants agree to share a room with another student – unless previously discussed with Spirit of EAGLES for AAIP leadership.

7. Participants will provide updates to contact information and/or stay in touch with Spirit of EAGLES and AAIP, sharing updates when major milestones are reached.

8. Spirit of EAGLES will provide justified airfare/transportation, lodging, and registration costs.

9. Spirit of EAGLES and AAIP will provide opportunities to stay involved with programs and to apply for ongoing/future support.

Please indicate agreement and provide signature.

I agree to follow the scholarship guidelines (below) if I am selected to receive a scholarship for the 2016 AAIP Annual Meeting.

Signature:______Date:______Please accept my typed name as my digital signature.

Please submit your application to Marcy Averill at [email protected].