Summer Student Research Application

If you would like to apply to our high school summer student research program, an undergraduate summer student research program, or a medical student summer research program, please fill out the following application.

Note: Since we cannot guarantee the privacy of electronic transmissions at this time, we ask that you complete the application, print it out and submit it by mail or by fax.


Mail to:
Susan Galandiuk, MD
Program Director
Section of Colon & Rectal Surgery
University of Louisville
Department of Surgery
550 South Jackson Street
Louisville, KY 40202

Fax to:
502-852-8915

Summer Student Research Program Application Form
Section of Colon & Rectal Surgery
University of Louisville

Type of Research Opportunity Sought:
___ High School Summer Student Researcher
___ Undergraduate Summer Student Researcher
___ Medical Student Summer Researcher (first year medical students)


Name: _______________________________________________________

Gender: ______________________________________________________

Birth Date: ____________________________________________________

Address: _____________________________________________________

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City/State/Zip Code

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Country

Telephone: ____________________________________________________
Home/Office/Cell Phone

Email: ________________________________________________________


Current Educational Activity:

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Current Educational Goals:

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Ultimate Career Goals:

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How did you hear of the availability of research opportunities at this laboratory?

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Mail to: Susan Galandiuk, MD, Program Director, Section of Colon & Rectal Surgery, University of Louisville, Department of Surgery, 550 South Jackson Street, Louisville, KY 40202

Fax to: 502-852-8915

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