Economic Epidemiology Advanced Study Institute, July 20 - July 31, 2009 and Workshop August 3 - 5, 2009

Advanced Study Institute and Workshop Application Form

Please apply by filling out the following blanks. Note that your application is complete when we have received:
1. this electronic application form
2. a statement of interest and commitment from you (uploaded through the website, .pdf and .doc files only)
3. a letter of recommendation (uploaded through the website, .pdf and .doc files only).
4. a letter from your mentor specifically committing to work with you upon your return from the Institute (uploaded through the website, .pdf and .doc files only).
The due date for receipt of ALL materials is March 1, 2009.

The due date for receipt of ALL materials is March 21, 2009 for Canadian applicants.

Participants should submit their applications to DIMACS:

When finished, press the "send" button at the bottom of the form.

What are you applying to attend?
Weeks 1 and 2 of the Institute (and following workshop)
Week 2 only of the Institute (and following workshop)

Who are you? Your First Name: Your Middle Name: Your last Name:
Your address? Institution: Department: Address Line #1: Address Line #2: Address Line #3: Daytime Phone: Cellphone:
Your E-Locations? E-Mail: Web page:
What degrees have you completed? Bachelors: Area: Institution: Year Completed: Masters: Area: Institution: Year Completed: Ph.D.: Area: Institution: Year Completed: Other: Area: Institution: Year Completed:
Where are you in your current program of study? Area:
Year 1, M.S. Year 2, M.S. Year 3, M.S. Year 4, M.S. 5+ Years, M.S. Year 1, Ph.D. Year 2, Ph.D. Year 3, Ph.D. Year 4, Ph.D. 5+ Years, Ph.D. Other:

Who will write a letter of recommendation supporting your application?
Title: Name: Phone:

Who will be your mentor in continuing your work on your Institute research project?
Title: Name: Phone:

Some optional information which we are required to track, since this is a federally funded program. You are not obligated to answer these questions:
Birthdate: (format mm/dd/yy)
Gender: M F
Are you a U.S. Citizen Permanent Resident non-U.S.Citizen ?
If not a U.S. citizen or permanent resident, please list country of citizenship:

What is your background in mathematical epidemiology?
Little or none (e.g. attended a few talks)
One or more courses

Have you had coursework that includes SIR modeling? yes no What calculus have you completed? Differential calculus? yes no Integral calculus? yes no Multivariable calculus? yes no Have you had any linear algebra courses? none one course two or more courses Have you had any statistics courses? none one course two or more courses Have you had any coursework in elementary differential equations in one and two variables? yes no
List of relevant math and biology courses you have taken: (please indicate if it is a grad level course or an undergrad level course)
1: 2: 3: 4: 5: 6: 7: 8: 9: 10: 11: 12:
What is your proficiency with computer algebra and graphical software?
MatlabNone Beginner Intermediate Advanced
MathematicaNone Beginner Intermediate Advanced
gnuplotNone Beginner Intermediate Advanced
Maple None Beginner Intermediate Advanced
Octave None Beginner Intermediate Advanced

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Last modified Decmeber 17, 2008.