Affiliate Scholar Application Form

Please provide the following information to apply for Affiliate Scholar. Applications will be processed on the first business day of each month.

Contact Information

First Name

Middle Name

Last Name

Date of Birth

Work/School Email

Personal Email

Mobile Number

Academic Information

Institution Association **If you are a high school or middle school student, please provide school name.

UC Davis

LLNL

High School or Middle School Student

Other…

High School Name

Position Title

Primary Department

Mentor Name

Applicants must have a mentor to be an affiliate. A mentor could be a science teacher they admire, a student club leader they work with, a guidance counselor, or a similar adult who is providing academic, career, or scientific guidance.

Mentor Name

Applicants must have a mentor to be an affiliate.

Mentor Email

Your Degrees Achieved

If you are currently in high school, middle school or your educational status is not listed below, please select "Other" and specify when you will receive your diploma.

Re-order	Degrees	Month	Year	Weight	Operations
	Degrees Degrees Enter other…	Month	Year	Item weight

more items

What type of degree are you pursuing now or intend to pursue next?

Research Area Interests

(Including relation to cancer)

Career Goal

Have you participated in UC Davis Comprehensive Cancer Center workshop, symposia, or other similar event yet?

Yes

If yes, which event/s or program/s?

Have you participated in community outreach or fundraising for cancer research yet?

Yes

Please share why you would like to be affiliated with UC Davis Comprehensive Cancer Center.

Are you currently enrolled in an institutional training grant (e.g, T32, R25) at UC Davis?

Yes

Please upload your CV or biosketch

Maximum 2 files.
100 MB limit.
Allowed types: pdf, doc, docx.

ORC ID

ORCID, which stands for Open Researcher and Contributor ID, is a digital identifier (an ORCID iD) that distinguishes you from other researchers. An ORCID can be connected to professional information including affiliations, grants, publications, and more. It helps ensure you get recognition for your contributions to science. If you don’t already have an ORCID, sign up here.

ORC ID Number

Background Survey

The UC Davis Comprehensive Cancer Center is committed to promoting equity, inclusion, and diversity. Demographic background information is collected to evaluate if our affiliates represent the diversity of the catchment area, the state, and the nation.

Any data that is reported is in aggregate form only and non-identifiable. Further, data will only be used to describe the affiliate scholar population to the National Institutes of Health (NIH) as part of the reporting requirements for the P30 Cancer Center Support Grant (CCSG). The Cancer Center never shares individual data with any internal UC Davis unit or external organization.

We recognize that the complexity of gender and the experience of race and ethnicity are not accurately represented by the categories below dictated by NIH. We invite you to select the categories that closely align with your gender, race, and ethnicity.

Gender

Race

Do you identify as Hispanic or Latino?

Do you identify as a person with a physical or mental disability?

Do TWO OR MORE of the following categories apply to you (either previously or currently)? These categories represent the NIH's recently expanded definition of a scientist from a disadvantaged background.

Are you currently or were you ever homeless, as defined by the McKinney-Vento Homeless Assistance Act? (Definition)
Are you currently or have you been in the foster care system, as defined by the Administration for Children and Families? (Definition)
Are you currently or were you eligible for the Federal Free and Reduced Lunch Program for two or more years? (Definition)
Do you have parents or legal guardians who have not completed a bachelor’s degree? (see report)
Are you currently or were you ever eligible for Federal Pell grants? (Definition)
Have you ever received support from the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) as a parent or child? (Definition)
Did you grow up in one of the following areas:
- a U.S. rural area, as designated by the Health Resources and Services Administration (HRSA) Rural Health Grants Eligibility Analyzer (link)
- a Centers for Medicare and Medicaid Services-designated Low-Income and Health Professional Shortage Areas (qualifying zip codes: link)

Do not fill out this field