2021 International Collaboration and Exchange Program Registration Form

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Registration form for program participants- Before you sign up :1) please ensure that you will have time to commit to the full program for the small group sessions and the large group conferences (you will meet once in the small group and once in the large group per month and two times total for the conferences); 2) if your school needs permission to participate please ensure your ICE program faculty approved

Email *

Name (first and last) *

I am a student at *

Medical University of Vienna, Austria

The University of Sydney, Australia

McGill University, Canada

University of Helsinki, Finland

University of Copenhagen, Denmark

Ludwig Maximilians University, Munich, Germany

Martin Luther University, Halle, Germany

Kyoto University, Japan

Tokyo Women's Medical University, Japan

King's College, London, UK

Columbia University, New York, USA

National Taiwan University, Taipei, Taiwan

University of Cambridge, Cambridge, UK

University Paris Descartes, Paris, France

Yale University, New Haven, USA

Stanford University, Stanford, USA

University of California San Francisco, USA

University of California San Diego, USA

Keio University, Tokyo, Japan

University of Barcelona, Barcelona, Spain

Chinese University of Hongkong (you can only participate in the virtual portion - no exchange travel or research option, please do not select options)

Other:

I am a *

medical student

dental student

MD PhD student

MD MS student

Undergraduate premedical student (Columbia University

Undergraduate premedical student (non-Columbia)

Public Health

Graduate student in health sciences (PhD candidates)

PhD nursing student

Other:

Required

Email address 1 (school email)

Email address 1 (private email that you frequently check)

I am an international student at my school. I am originally from ..... (list your country and/or citizenship). We want to include many different countries! Type "no applicable" if you are a citizen in the country where you study.

ICE Research Pod group placements. Are you interested in group summer research projects arranged via the ICE program? ICE Research Pod projects can be conducted online or via ICE travels in summer. You will work with other students from other ICE partner countries under the supervision of a professor from a partner school. Slots are limited. Only students who participate well in the program will be included in the group summer research. *

Yes (we will place you)

Maybe (you will not be placed until you confirm your need for placement)

Summer travel exchanges. Are you interested in the ICE in person exchange travels? Only students who perform well in the program can be placed. Most schools have a preselection process (except the US and Cambridge). Please note that "Yes- I commit to travel" is a binding commitment. You cannot cancel. For option "Yes - but I cannot commit" the deadline to be added to the travel list will be early December. Please note option "Yes, I commit to my first three choices only" is dependent on availability. You cannot be added to the travel list for other choices at a later timepoint.

Yes - I commit to travel and will secure funding

Yes - I commit to travel to my first three choices only

Yes- I am interested in travel but I cannot commit without funding (you will be placed on the waitlist)

Clear selection

Preferred university for exchange travel ("no preference" has the highest chance for placement) Please note the program is a virtual networking program with limited exchange positions. When committing to travel you are signing up to network with your peers in the partner schools while you are there. Assignments in 2022 are dependent on the local situation with COVID-19.

Medical University of Vienna, Vienna, Austria

The University of Sydney, Sydney, Australia

McGill University, Montreal, Canada

University of Copenhagen, Copenhagen, Denmark

University of Helsinki, Helsinki, Finland

University of Paris, Paris, France

Ludwig Maximilians University, Munich, Germany

Martin Luther University, Halle, Germany

Keio University, Tokyo, Japan

Kyoto University, Kyoto, Japan

Tokyo Women's Medical University, Tokyo, Japan

King's College, London, UK

University of Cambridge, Cambridge, UK (very limited number of positions)

National Taiwan University, Taipei, Taiwan

National Seoul University, South Korea (very limited number of positions, dental students only)

University of Barcelona, Spain

Columbia University, New York, USA

University of California San Francisco, San Francisco, USA

University of California San Diego, San Diego, USA

Stanford University, Stanford, USA (very limited number of positions)

Yale University, New Haven, USA (very limited number of positions)

Other:

Please list your first choice school for student exchange from the list above. You can select up to 2 schools from one country. "No preference" has the highest chance for placement.

Please list your second choice school for student exchange from the list above. You can select up to 2 schools from one country. "No preference" has the highest chance for placement.

Please list your third choice school for student exchange from the list above. You can select up to 2 schools from one country. "No preference" has the highest chance for placement.

Research interest (i.e. "Immunology",... if no preference write "zero". The more specific you are the less likely is a match and placement)

I am

female

male

non-binary

prefer not to disclose

Other:

Clear selection

I am

between 18 and 20 years old

between 20 and 25 years old

over 25 years old

under 18 years of age

prefer not to disclose

Clear selection

Enter your year of school *

Preclinical medical

Clinical medical

Preclinical dental

Clinical dental

MD PhD student

MD MS student

Undergraduate college (premedical)

Other:

Phone number (start with country code)

Whatsapp number or email (if you have)

Facebook name (if you have)

Instagram ID (if you have)

Twitter ID (if you have)

Prior basic science research experience

none

very little

moderate

very good

Clear selection

Prior data analysis research experience (statistics, data charting,..)

none

very little

moderate

very good

Clear selection

Columbia students only - I have sent my consent forms to Dr. Wu. Please see website - in 2021 we may not need a consent. The program will notify Columbia students if consents are waived. *

Yes

Not a Columbia student

Faculty approval obtained (please note, that for some schools students can only travel if pre-approved by local Faculty. You can still participate in the virtual portions of program without Faculty approval, but you may not travel). *

Yes (you need to contact your local faculty member to have your name included in the travel application list)

Not needed at my school (Columbia, Cambridge, Yale, Stanford, UCSF)

Other:

If you are traveling over the summer are you willing to sublet your apartment to incoming ICE students?

Yes

Maybe

Clear selection

Are you willing to serve as a National Student Leader or conference moderator?

Yes

Clear selection

Are you willing to serve as a "buddy" and socialize with incoming ICE travel students in summer? *

Yes

Are you interested in being a social leader for the travel students next summer (i.e. organizing social activities for the incoming students?) *

Yes

I commit to the full program and will check my email and the website for updates. If I need to drop out I will notify my National Student Leaders, my group and the program immediately. *

Yes

I consent that photos taken at the virtual conferences can be published with my name and face on it. We publish on Instagram and our website. *

Yes

Program selection question - in a short essay please outline why you would like to participate in the program. Share with us your goals and why you think you are a good candidate for this program (this essay will be used to select your participation) *

I confirm to commit to the full virtual portion of the program. - Please note that the program hast limited participation slots for each university and that you are taking away a slot for another student by dropping out. *

I understand and confirm to commit to the full virtual program. If there is an emergency I will let the program and my senior leaders know.

Do not forget to fill out the pre program questionnaire: https://cumc.co1.qualtrics.com/jfe/form/SV_6L6f84nr8dnpUj4 *

Yes, I have filled out the questionnaire

Yes, I will fill it out later

No, I decline participating in the questionnaire

Other:

I am interested in analyzing research data on the program in the future (scholarly research work/ optional research with Dr. Wu and other ICE faculty members)

Yes

Clear selection

Submit

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