Stipend Promoting Ophthalmology Diversity Interest Form
Please complete this form if interested in a $1,500 stipend while rotating at the Kellogg Eye Center in June, July, August, or September 2021.
The stipend is intended to offset costs associated with participating in a rotation at the Kellogg Eye Center, Michigan Medicine. Students with prior research and/or volunteer efforts in the realm of diversity, equity, and inclusion should apply.

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Name: *
Email: *
Medical School: *
Preferred Rotation: *
Required
Please explain prior research and/or volunteer efforts in the realm of diversity, equity, and inclusion: *
Please explain why you would like to be considered for the stipend:
Do you self-identify as any of the following? (select all that apply)
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