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Summer Institute for Medical Students Application

Please Print and Fax/Mail this form back to the Betty Ford Center.

Remember, your application is not complete without the attachments. See #7 below for the checklist.

Confidential Information

Please Complete The Following:

First Name:
Middle Name:
Last Name:
Street Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Birth Date:
E-Mail Address:
Social Security Number:
Age:
Sex: Male      Female
Marital Status:
Name of Medical School:
(No abbreviations please)
Year in School:


Contacts In Case Of Emergency:

1.
Name:
Relationship:
Address:
Phone:
 
2.
Name:
Relationship:
Address:
Phone:

Do you have involvement with chemical dependency?
Personal      Professional
Please Explain:

Previous Training in the Chemical Dependency Field:

Please select the level of care (Family, Inpatient, Day Treatment) in order of preference you wish to participate in. We will make every effort to place you in the program you request, but we cannot guarantee you your choice.

First Choice: Inpatient Family Day Treatment
Second Choice: Inpatient Family Day Treatment
Third Choice: Inpatient Family Day Treatment

 

2010 Session dates are as follows:

Please mark all dates you are available and indicate your session preferences below

May 17 - May 21
May 31 - June 4
June 14 - June 18
June 28 - July 2
July 12 - July 16
July 26 - July 30
August 9 - August 13

 First Choice:
Second Choice:
Third Choice:
Fourth Choice:
Fifth Choice:
Sixth Choice:
Seventh Choice:

Acknowledgment of the following statements is required:

1. I understand that the Summer Institute for Medical Students is experiential and not training or personal therapy.

2. I understand this application is confidential and will be kept on file.

3. I understand that the selection process will be based, in part, on the quality of the complete application packet, including recommendation letters and the essay.

4. I clearly understand that the experience provided by this program includes attendance in group therapy and other sessions, which may be emotionally charged, and I assume responsibility for any personal issues that may arise as a result thereof.

5. I acknowledge that the Summer Institute for Medical Students is a 5 day commitment, and I will arrange my school schedules so that I am able to participate from 7:00 am Monday through the 4:30 pm Friday conclusion of the program.

6. To the best of my knowledge, the information contained in this application is true.

7. My application packet is complete:

Application
Application Cover
Curriculum Vitae
Two current letters of recommendation to the Betty Ford Center.
Essay (one page typed)

______________________________________________
Applicant Signature

NOTE:  Preferential program placement will be offered to those who apply before March 5, 2010. We must receive your completed application packet no later than Friday, March 19, 2010. This will ensure that you are considered for participation in one of the sessions.

Thank you for your interest.

You may FAX or mail your completed packet to:

Betty Ford Center Training Department
39000 Bob Hope Drive
Rancho Mirage, CA 92270

Local: (760) 773-4108
Toll Free: (800) 434-7365 Ext. 4108
Fax: (760) 773-1508

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