CEYE Collaborator Form

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Are you interested in working with the Center for Excellence in Youth Education (CEYE) to positively impact minority and disadvantaged youth in NYC in some capacity? Please take a look at some of the options available on our CEYE Collaborator Index (linked below), then use the below form to provide us with some information about you. We will reach out to you for follow-up.

CEYE Collaborator Index: http://bit.ly/CEYECollaboratorIndex

If you consider this to be time sensitive please be sure to reach out to us at CEYE@mssm.edu.

We look forward to collaborating with you!

Email *

Prefix

e.g. Mr., Ms., Mrs.

First Name *

Last Name *

Suffix

e.g. Jr., Sr.

Phone number *

Please provide the best number to reach you by

Alternate Phone number

Please provide the best number to reach you by

Which role best describes you? *

Check all that apply

Parent of a current CEYE Student or Alumni

CEYE Alumni

Current Medical School Student

Current Graduate School Student

Mount Sinai Clinical Faculty

Mount Sinai Research Faculty

Mount Sinai Staff

Research Trainees (e..g Post-doc Fellow)

Clinical Trainees (e.g.Physician Resident)

Other:

Required

Which department are you a part of? (write N/A if not applicable to you) *

Have you previously supported or participated in any of the Mount Sinai sponsored pipeline programs below? *

Please check all that apply.

MedStart Enrichment (summer camp or events)

GEMS (Girls Empowered through Medicine & Science)

Neuroscience 101 w/ MiNDS (Mentoring in Neuroscience Discovery at Sinai)

Mount Sinai Brain Fair

MedDOCS (Medical Discovery of Careers)

First Generation Scholars Program

CEYE Junior High School Program (Day-with-a-Scientist Series)

CEYE High School Program (If yes, list the program name(s) and year in the "Other" checkbox)

Summer Undergraduate Research Program (SURP)

I have not participated in any programming yet!

Other:

Required

If you participated in any Mount Sinai Programs, in what capacity were you involved with the program? Please click all that apply *

Student

Mentor

Facilitator

Instructor

Financial Supporter

I have not participated in any Mount Sinai programs

Other:

Required

Please select one or more of the below options in which you are interested in collaborating with CEYE: *

Please refer to the CEYE Collaboration Form for detailed descriptions: http://bit.ly/CEYECollaboratorIndex

Scientific Lectures, Career Talks, and Panels

Laboratory or Hospital Tour

Classroom “Take Over”

Virtual Research Internships

The North East Regional Alliance (NERA) MedPrep Program

Other:

Required

Please include specific skills or experience you feel you can contribute to CEYE. *

Are you interested in making a gift or donation to CEYE? *

If you check YES, the CEYE Team will be in communication with you about next steps.

Yes, I 'd be happy to support.

No, not at the moment.

Are you interested in meeting with CEYE in regards to a collaborative grant submission and/or funding opportunities? *

If you check YES, the CEYE Team will be in communication with you about next steps.

Yes, I am interested in grant and/or funding opportunities with CEYE

No, not at the moment.

Please feel free to share anything else you'd like us to know! *

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