Fellowship Student Application 123456 Step 1 of 5Student Name First Last Address Street Address City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Email (Please provide a non-university email) PhoneLinked In Facebook Instagram Twitter Step 2 of 5Profile PhotoAccepted file types: jpg, png, Max. file size: 300 MB.Cover LetterAccepted file types: pdf, Max. file size: 128 MB.ResumeAccepted file types: pdf, Max. file size: 128 MB.University TranscriptAccepted file types: pdf, Max. file size: 128 MB.2 Letters of RecommendationAccepted file types: pdf, Max. file size: 128 MB. Step 3 of 5Check the areas you would like to focus on during your fellowship (select all that apply): Municipal policy research/development Regional policy research/development Coalition development General plan update or health element in general plan Advocacy for, or promotion of, changes in the built environment Active Transportation/Physical Activity Community advocacy Health advocacy Policy-centered health promotion Evaluation Multi-sector Collaborative Initiatives Other Other Geriatric Health, Obesity Environmental justice/sustainability Poverty, Food Security, Homelessness Health counseling, prevention counseling specifically against chronic disease, improve lifestyle behavior, COVID-19 protocols Access to healthy foods, homeless & low income housing Nuclear Engineering projects. There is a bit of all of these. Research driven teaching and projects Data analysis and epidemiological surveillance Planning, economic development, housing, homelessness, revitalization plans for downtown Health education/promotion Step 4 of 5How often would you like to meet with your preceptor/mentor/supervisor? Daily Weekly Bi-weekly Monthly What would be your preferred mode of contact with your preceptor/mentor/supervisor? Face-to-face Phone Text E-mail, Zoom or Microsoft Team Meetings Video Chat Other (please describe) Other Mode of Contact Step 5 of 5How comfortable are you with having your project remotely? Not Comfortable Very Comfortable Other (please describe) Others for Project RemotelyWhat professional development topics would you like to discuss with your preceptor/mentor/supervisor?(Mark all that apply) Professionalism Career development Public Health Field Policy Development Networking Resume development Other (please describe) Other Professional Development Topics Final StepWhat are your academic/research interests?What are your non-academic or work-related interests/hobbies?Community Involvement SynopsisTell us about yourself and why you would make a good Randall Lewis Fellow?PhoneThis field is for validation purposes and should be left unchanged.
