ABSTRACT SUBMISSION
1. Contact Information
Name
First
Middle
Last
Suffixes
(degree obtained)
BS
MS
MD
PhD
MD/PhD
Other (specify)
Mailing Address (Preferred address to receive postal mail)
Institution (if applicable)
Street
Apartment/Suite
City
State
Zip code
Phone
Cell Phone
E-Mail
Must be valid - You will receive a confirmation e-mail at this address.
2. Additional Registration Information
Date of Birth
MM/DD/YYYY
Gender
Female
Male
Ethnicity (Optional)
African American
American Indian/Alaska Native
Hispanic (specify)
Asian American/Pacific Islander (specify)
White Non-Hispanic
Other (specify)
3. Institution, Academic Level, Expected Year of Completion (of submitting author only)
Current School/Institution
School/Institution Address
Street
City
State
Zip code
Phone
Academic Background
Date of Entry
Degree(s) Expected
Expected Year of Graduation/Program Completion
Major/Field of Study
Academic Level (check only one)
Postdoctoral/Research Fellow (please specify)
MD
PhD
MD/PhD
Other
MD/PhD Candidate
PhD Candidate
MD Candidate
DMD/DDS Candidate
Master's Candidate
Post-baccalaureate
(Please specify below your graduation year and name of the school)
College Student
Community College Student
Other (specify)
4. Name of author
Author and Affiliation
Name of submitting author
Submitting author's school/institution
Institution where the research was conducted
Co-Authors and Affiliations - Provide names and institutions for any collaborators on the research. Please make sure the co-authors are aware their names are being submitted.
5. Research Title & Category
Title: (for example, "The Effect of Hospital Type on Lymphoma Outcomes in Boston")
Category: Please select which category best describes the research. If none of the categories below are appropriate, please check "Other" and type a new category in the space provided.
Public Health, Epidemiology, or Biostatistics
Microbiology, Immunology, Genetics, or Molecular Biology
Cellular Biology, Neuroscience, Biochemistry, or Physiology
Bioinformatics, Physcis, Chemistry, Engineering
Clinical or Social Science
Other (specify)
6. Funding source(s)/Research sponsor(s) Provide names of any sponsors of the research being submitted for presentation.
Provide the funding source(s).
7. Abstract (not to exceed a total of 400 words) must demonstrate the scientific problem and must
clearly contain :
Hypothesis/statement of the problem/research question/background
Methods used in the investigation
Summary/results of the investigation
Conclusion of the investigation/interpretation of results
Need help writing your abstract?
Abstract must be typed into the following four separate sections.
Hypothesis/statement of the problem/research
question/background
Methods used in the
investigation
Summary/results
of the investigation
Conclusion of the
investigation/interpretation of results
The abstract cannot exceed 400 words.
8. Have you ever participated in the New England Science Symposium?
Please read and sign below
By signing this application, I (or my parent or guardian on my behalf) hereby:
(A) acknowledge(s) and understand(s) that Harvard Medical School (HMS) Office for Diversity and Community Partnership and the Biomedical Science Careers Program, Inc. (BSCP) will retain the information in this application for its records , and that this information about the applicant, including identifying information, will be used to match students with advisors, track students through their academic and professional careers, and for future promotional and other communications, such as newsletters;
(B) consent(s) to photographic, audio, video, or electronic images of the applicant to be used by HMS and BSCP for exhibition, public display, publication, news media story, video, audio, or other electronic media, such as the Internet, television, CD-ROM, or DVD ;
(C) release(s) HMS and BSCP, including each of their directors, officers, employees and agents, waive(s)s all known and unknown claims against any of them, and agree(s) not to sue any of them on account of or in conjunction with any claims, causes of action, injuries, damage, cost of expenses arising out of the applicant's participation in the Symposium, whether or not caused by the acts, omissions or other fault of the parties being released; and
(D) acknowledge(s) and represent(s) that he or she has carefully reviewed this application, including the foregoing acknowledgement, consent, release, waiver and agreement not to sue and understand(s) what each of them mean, and that my/their signature below indicates that delivery of this application to HMS/BSCP is my/their free act and deed.
Name
Signature (your initials)
Date
MM/DD/YYYY
Please complete below if applicant is less than 18 years of age
Parent/Caregiver's Name
Parent/Caregiver's Signature (initials)
Date
MM/DD/YYYY
The symposium is supported by the National Institutes of Health through the Cooperative Agreement between Harvard Medical School Minority Faculty Development Program and the Office of Minority Health, Department of Health and Human Services.
Cooperative Agreement No. MPCMPO51007
Contacts
For more information please contact:
Harvard Medical School
Geeta Chougule
Phone: 617-432-7770
geeta_chougule@hms.harvard.edu
Biomedical Science Careers Program
Lise D. Kaye
Phone: 617-432-0552
lise_kaye@hms.harvard.edu
If you have problems submitting the form,
please contact Ferhan Gomulu at 617.432.1849 or 617.432.0552