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Application for High School
Research Opportunity

Please complete the entire application

Name:
Date of Birth:
Social Security #:
Gender: Male Female

Address:
Apt #:
City:
State:
Zip:

Phone Number:
Email:
Alternate Phone:
Alternate Email:

What high school do you attend?
Grade:
What are you working on? Science Fair Project Senior Thesis

Citizenship:
Are you a permanent resident alien? Yes No

Area of Research Interest (please choose in order of interest):

Why do you want to do research at MUSC? (ex. Science Fair, Senior Thesis...) *up to 255 characters
You have 255 characters remaining for your description...

For what length of time do you expect to do research at MUSC?

Do you have any relatives who are currently employed at MUSC? Yes No

If "yes" give name, relationship and department:

Have you already contacted someone at MUSC regarding work in the lab? Yes No

If "yes" give name and department:

I understand that the Medical University of South Carolina reserves the right to accept or reject my application in its sole discretion and that the above statements made in this application are true and correct. I understand and willingly agree to perform the above-referenced opportunity with no compensation. I understand that should I become ill or injured while performing in this capacity, I will NOT be covered by MUSC's Worker's Compensation. I understand that it will be necessary to obtain any required medical attention from my family physician, and I release and hold MUSC harmless from any implied liability.

Accept Conditions

Health Requirements:

All MUSC volunteers, employees and visiting students are required to be processed through MUSC Health Services. A Human Resources Management Consultant will schedule you for an appointment. Please provide documentation of the following:

Verification of two MMR vaccines (mumps, measles, rubella)
Verification of a PPD skin test within 3 months. (TB test)
Tetanus shot within 10 years.
Positive Varicella IgG Titer or TWO Varicella Vaccines (Vaccination Dates must include month/day/year). History of Chicken Pox verified by a physician is also acceptable.

OSHA Requirements:

OSHA Training is mandated by OSHA and required by law. The training is competence based and includes four sections. For each training section, you are required to read all materials and then answer all questions correctly before you will be allowed to move to the next section. The training can be interrupted at any time and can be resumed at your convenience. To access the training module now, go to the MUSC OSHA Online Training at:

https://www.carc.musc.edu/training/modules/osha

Follow the directions that begin with:
"If you are a new employee and have not received your NetID login or password..."

Once you click on the "Register Here" link, you will be asked for an email address. A confirmation email will be sent to that address. Just open the email. Then go back to https://www.carc.musc.edu/training/modules/osha and click on the link for each of the four modules listed (Bloodborne Pathogens/Fire and Life Safety Training/Hazard Communication/Personal Protective Equipment).

Complete each module. Once completed, print out the completion certificate and return it with the rest of your completed paperwork.

Other Required Paperwork:

Medical University of South Carolina Consent for Minors Studying or Observing in a MUSC Laboratory (to be completed for a minor - under the age of 18 years).
Medical University of South Carolina Code of Conduct form.
Health Consent for Minors Form.
Latex Allergy Questionnaire

Please submit all of the above paperwork and the application to:

Debbie Shoemaker
Director of Summer Programs
173 Ashley Ave - BSB 102
MSC 501
Charlestion, SC 29425-5010
Phone: 843-792-9620
Fax: 843-792-6590
Email: shoemakd@musc.edu

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