Single Application Form I am applying for*An Environmental FellowshipA Traditional FellowshipEither Fellowship (we will consider you in each category)Contact and School Affiliation InformationName* First Last Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Preferred Email* Enter Email Confirm Email Will you be enrolled in a degree-granting program through April 2019?*YesNoWill you be enrolled in a degree-granting program through December 2018?*YesNoIn what year of your degree program will you be during the 2018-2019 academic year?*FirstSecondThirdFourthOtherWhen is your expected graduation date?*Please enter month and yearYour school*Select oneBoston University Sargent College of Health and Rehabilitation SciencesBoston University Goldman School of Dental MedicineBoston University School of MedicineBoston University School Public HealthHarvard Medical SchoolMGH-Institute of Health ProfessionsNew England College of OptometrySimmons College College of Arts and SciencesSimmons College School of ManagementSimmons College School of Nursing and Health SciencesSimmons College School of Social WorkTufts University Friedman School of Nutrition Science and PolicyTufts University School of Dental MedicineTufts University School of MedicineOtherYour school*Select oneAdler UniversityArgosy UniversityChicago School of Professional PsychologyChicago State UniversityChicago-Kent College of LawColumbia College ChicagoDePaul UniversityDominican UniversityGovernors State UniversityIllinois College of OptometryIllinois Institute of TechnologyLewis UniversityLoyola University ChicagoMalcolm X CollegeMidwestern UniversityNational Louis UniversityNational University of Health SciencesNorth Park UniversityNortheastern Illinois UniversityNorthern Illinois UniversityNorthwestern UniversityPacific College of Oriental MedicineResurrection UniversityRoosevelt University of Medicine and ScienceRosalind Franklin UniversityRush UniversitySaint Xavier UniversityThe School of the Art Institute of ChicagoThe University of ChicagoUniversity of Illinois at ChicagoUniversity of St. FrancisOtherYour school*Select oneOhio StateOhio UniversityTrinity Lutheran SeminaryOtherYour school*Select oneSouthern Methodist UniversityBaylor University, Louise Herrington School of NursingTexas Christian UniversityTexas Woman’s UniversityUniversity of DallasUniversity of Texas at ArlingtonUniversity of Texas at DallasUniversity of Texas Southwestern Medical CenterOtherYour school*Select oneBaylor College of MedicineUniversity of Texas School of Public HealthUniversity of Texas Medical Branch at GalvestonUniversity of Texas Medical SchoolUniversity of Texas Dental Branch at HoustonUniversity of Houston Graduate College of Social WorkUniversity of Houston College of PharmacyUniversity of Houston College of EducationUniversity of Houston College of SociologyUniversity of Houston Clear LakeUniversity of Houston Law CenterUniversity of Houston Psychology DepartmentHouston Baptist UniversityTexas Southern UniversityRice UniversityOtherYour school*Select oneUniversity of California, Los AngelesUniversity of Southern CaliforniaWestern UniversityLoma Linda UniversityCharles Drew UniversityUniversity of California, IrvineOtherYour school*Select oneLouisiana State University School of DentistryLouisiana State University School of MedicineLouisiana State University School of Public HealthLoyola University College of Music and Fine ArtsLoyola University School of LawSouthern University of New Orleans School of Social WorkTulane University School of LawTulane University School of MedicineTulane University School of Public Health and Tropical MedicineXavier University School of PharmacyOtherYour school*Select oneGeisel School of Medicine at DartmouthThayer School of Engineering at DartmouthUniversity of New Hampshire School of LawUniversity of Vermont College of MedicineVermont Law SchoolOtherYour school*Select oneCampbell University School of PharmacyCampbell University School of Osteopathic MedicineDuke University School of MedicineDuke University School of NursingDuke University Fuqua School of BusinessDuke University School of Physical TherapyDuke University School of Physician AssistantDuke University School of LawEast Carolina University Brody School of MedicineEast Carolina University School of Dental MedicineNorth Carolina Central University College of Behavioral and Social SciencesNorth Carolina Central University School of EducationNorth Carolina Central University School of LawUniversity of North Carolina – Chapel Hill School of DentistryUniversity of North Carolina – Chapel Hill School of Public HealthUniversity of North Carolina – Chapel Hill School of MedicineWake Forest School of MedicineWake Forest School of DivinityWake Forest School of LawWinston-Salem State University School of Health SciencesOtherYour school*Select oneDuquesne University, School of Occupational TherapyLake Erie College of Osteopathic Medicine at Seton HillPittsburgh Theological SeminaryPoint Park University, School of CommunicationRobert Morris UniversitySeton Hill University, Physician Assistant ProgramSlippery Rock University, School of NursingUniversity of Pittsburgh, School of AnthropologyUniversity of Pittsburgh, School of BioengineeringUniversity of Pittsburgh, School of Dental MedicineUniversity of Pittsburgh, School of LawUniversity of Pittsburgh, School of MedicineUniversity of Pittsburgh, School of NursingUniversity of Pittsburgh, School of Occupational MedicineUniversity of Pittsburgh, School of PharmacyUniversity of Pittsburgh, School of Public HealthUniversity of Pittsburgh, School of Social WorkOtherYour school*Select oneSamuel Merritt UniversitySan Francisco State UniversityStanford UniversityTouro UniversityUniversity of California, BerkeleyUniversity of California, San FranciscoOtherYour school*Select oneUAB School of DentistryUAB School of Health ProfessionsUAB School of MedicineUAB School of NursingUAB School of Public HealthAlabama State UniversityTuskegee UniversityUniversity of AlabamaUniversity of MontevalloAuburn UniversitySamford UniversityOtherYour school*Select oneOklahoma State UniversityUniversity of OklahomaUniversity of TulsaOtherYour school*Please enter the name of your school*Discipline*Degree Program*Fellows are expected to participate in Fellowship activities throughout the year (April 2018-April 2019). Will you have significant academic/clinical responsibility during the Fellowship year that may interfere with your ability to participate in the Fellowship?*YesNoPlease describe*Please indicate any times you anticipate being out of the area and/or unable to participate in Fellowship activities for reasons other than those listed above (optional) Project InformationPlease describe the target population you wish to impact with your proposed community service project, including demographic information and the community need(s) your project would address (suggested word count 150):*Please describe your proposed community service project, including the following: project goals, and possible activities to meet these goals; intended outcomes you hope to see for the participants; if you are proposing to continue an existing program, please briefly describe how you might expand or build upon it (suggested word count 400):*What evidence do you have that such a project could be successful? Examples may be practice-based, pointing to a similar model in another location, or research-based, pointing to scientific literature demonstrating the effectiveness of your approach. If you do not know of such evidence, skip question.Proposed community agency (or agencies) project site (if a community agency has not yet been identified, please enter TBD):*If you are accepted as a Fellow, once your project is formed, you will be asked to evaluate your project's impact. Knowing that your evaluation strategies may change as the project is developed, please indicate what methods you have thought about using throughout the year to evaluate your project's effectiveness and determine how well your goals were met. (Suggested Word Count 200) Please refer to your local program's application guidelines for additional information.*For example, Fellows have often conducted baseline and follow-up surveys, provided journals to participants to record progress with individual goals, held periodic discussions with participants, or identified other ways to gauge how well community members were able to make and sustain healthy changes as a result of the project.Bearing in mind that the majority of your service hours should be spent in direct, face-to-face community service, how would you apportion your time throughout the Fellowship year? Please include a proposed start and end date (suggested word count 150):*For example, if you plan to meet weekly with your target population throughout the year, how many meetings would be required to fulfill direct service requirement? Be sure you have given some thought to the logistical aspects of this part of your project.Describe the avenues you will explore to sustain the project beyond your time as a Fellow (suggested word count 200): Personal and Professional Information as it Relates to the Fellowship ActivitiesConsidering that there are many different types of community service projects a Fellow could design, what inspired you to develop your particular project idea (suggested word count: 200)?*Personal Statement: Please include anything about your personal and professional background, as well as, motivation for applying to the Schweitzer Fellowship that you would like to share with the selection committee (suggested word count: 800).*One person listed below (only one) needs to write a Letter of Recommendation on his/her letterhead stationery and send it to arrive by 5 PM Friday, February 9, 2018 to: Joan Haley Pittsburgh Schweitzer Fellows Program 5614 Elgin St. Pittsburgh, PA 15206 Or e-mail it to: jhaley@schweitzerfellowship.orgReference 1 (Proposed Faculty Mentor)*Reference contact information, plus a sentence describing your relationshipReference 2*Reference contact information, plus a sentence describing your relationshipReference 3*Reference contact information, plus a sentence describing your relationshipPlease list someone at your proposed site who could serve as a Site Mentor or who has been your site contact. Include telephone number and email address. If a possible Site Mentor or contact has not yet been identified, please enter TBD.* Your CommitmentIf selected to serve as a Schweitzer Fellow, I will commit to the following: Perform at least 200 hours of service, with a minimum of 100 hours of direct service Attend an overnight orientation retreat April 28-29, 2018 Attend a day-long mid-year retreat on Oct. 20, 2018 Attend monthly Fellowship meetings on alternating weeknights, once per month Present a poster and oral project summary at the Celebration of Service April, 2019 If selected to serve as a Schweitzer Fellow, I will commit to the following: Perform at least 200 hours of service Attend an orientation retreat, April 6-8 and Celebration of Service in May (TBD). Please check the Bay Area website for updates on dates. If selected to serve as a Schweitzer Fellow, I will commit to the following: Perform at least 200 hours of service (at least half of which must be direct service hours) Attend the Celebration of Service on May 2018 and May 2019 (dates to be determined) Attend the following required retreats: overnight Orientation April April 14, 2018, mid-year retreat October 14, 2018 and end of year retreat April 28, 2019 Participate in at least 7 of 9 evening monthly meetings from May 2018 to April 2019. Participate in a group outreach project If selected to serve as a Schweitzer Fellow, I will commit to the following: Perform at least 200 hours of service Attend an overnight orientation retreat April 16-17, 2016 Attend a day-long mid-year retreat on November 19, 2016 (Tentative Date) Attend monthly Fellowship meetings Present at the Celebration of Service in April, 2017 (date TBA) If selected to serve as a Schweitzer Fellow, I will commit to the following: Perform at least 200 hours of service Attend the Celebration of Service on May 3, 2017 Participate in at least 8 of 10 evening monthly meetings from May 2017 to April 2018. If selected to serve as a Schweitzer Fellow, I will commit to the following: Perform at least 200 hours of service Attend an overnight orientation retreat April 7-8, 2018 Attend a day-long mid-year retreat in fall 2018, date to be scheduled Attend monthly Fellowship meetings Attend the Celebration of Service in May 2019 If selected to serve as a Schweitzer Fellow, I will commit to the following: Perform at least 200 hours of service Attend program orientation retreat April 2018 Attend a day-long mid-year retreat in fall 2018, date to be scheduled Attend monthly Fellowship meetings Attend the Celebration of Service in April 2019 If selected to serve as a Schweitzer Fellow, I will commit to the following: Perform at least 200 hours of service (100 hours for paired Fellows) Attend overnight orientation April 2016 Attend mid-year retreat October 2016, closing retreat April 2017 Attend monthly Fellowship meetings Attend Fellows Symposium March or April 2017 Attend Celebration of Service April 2017If selected to serve as a Schweitzer Fellow, I will commit to the following: Perform at least 200 hours of service. Although not required, we encourage that at least 100 of these hours be in direct, face-to-face, contact with your target population. Attend the Celebration of Service on April 6, 2018 and in April 2019 (date to be determined) Attend an overnight orientation retreat June 9-10, 2017 Attend a half-day mid-year retreat in November, 2018 (date to be determined) Attend monthly meetings, two absences are permitted. Participate in a group outreach project TBD If selected to serve as a Schweitzer Fellow, I will commit to the following: Perform at least 200 hours of service Attend an overnight orientation retreat April, 2018 Attend a mid-year retreat September, 2018 Attend monthly Fellowship meetings Share reflections at the Celebration of Service April, 2019 If selected to serve as a Schweitzer Fellow, I will commit to the following: Perform at least 200 hours of service Attend the Celebration of Service in April 2018 and 2019 (dates to be determined) Attend Orientation Retreat in spring 2018 Participate in at least 8 of 10 evening monthly meetings from April 2018 to April 2019 If selected to serve as a Schweitzer Fellow, I will commit to the following: Perform at least 200 hours of service (100 hours for paired Fellows) Attend the Celebration of Service on April 14, 2018 in Raleigh and in March/April, 2019 (date to be determined) Attend an overnight orientation retreat April 7 - 8, 2018 in Davidson Attend a mid-year retreat in September/October 2018 Attend a joint professional meeting in January, 2019 If selected to serve as a Schweitzer Fellow, I will commit to the following: Perform at least 200 hours of service. A minimum of 100 of these hours will be direct, face-to-face, contact with my target population. Send monthly reports to the Schweitzer Fellowship director, my site mentor and my academic mentor Attend the Welcome Reception/Celebration of Service, evening of Wednesday April 25th 2018 Attend an overnight orientation retreat from afternoon of Saturday April 28th 2018 through afternoon of Sunday April 29th 2018 at Post Oak Lodge Attend a mid-year retreat in October 2018 (date TBD) Attend monthly meetings Participate in a community advocacy/outreach project * I have read and agree to the terms above Upload your ResumePlease upload your resume in PDF format*Accepted file types: pdf.NameThis field is for validation purposes and should be left unchanged.