SMI Student Application

Above: The SMI 2023 team along with SMI faculty and interpreters preparing to head out for door-to-door health screenings.

SMI Philadelphia Student Application

June 15- July 6, 2024

Thank you for your interest in applying to the Philadelphia Summer Medical Institute! Please fill out the form below and submit it by March 15 to receive a decision by April 1. Those interested in securing your summer plans early may apply “early decision” by a deadline of February 15 to receive a decision on March 1. If it is past the deadline and you wish to apply for 2024, we will consider that! Please email [email protected] to discuss.

Note that each application is not complete without two letters of recommendation, one professional and one personal, sent to Holly Favino (details for each recommendation are included in the application form).

Finally, this application is web-based and may not be saved once you start it, and is not saved until it is submitted. You can leave it open on your screen as long as you are working on it. Because of the length of the form, you may find it easier to read through the form, compose the short answer questions in a separate document, and cut and paste them into the fields to prevent them from being lost if the application tab is inadvertently closed.

Please feel free to email any questions at any point in your application process to the SMI program director, Holly Favino.

Personal Information
Name*
First Last
Name You Go By*
SMI Year*
Gender*
- Male
- Female
Please upload a recent digital photo of yourself (headshot, please).*
Max. file size: 128 MB.
If accepted, this photo will be used for your clinic badge. Please submit a clear, professional-looking, individual photo of yourself.
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Cell Phone*
If married, spouse name:
School/Employer Name*
Anticipated Class / Grad Year*
Progam/Field*
- Allied Health
- Dentistry
- Medicine
- Nursing
- Pre-Med
- Physical Therapy
- Physician Assistant
Family and Church Information
Parent(s) Name*
Parent(s) Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Church*
Member?*
- Yes
- No
Pastor's Name*
First Last
Home Church Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Current Church
Current Church Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Background Information
Are you proficient in Spanish?*
- Yes
- No
Do you have health insurance? (Health insurance is required for all SMI student participants; if you do not have it, then you will need to acquire it before participating)*
- Yes
- No
Have you received three doses of Hepatitis B vaccine?*
- Yes
- No
Are you up to date on all vaccines?*
- Yes
- No
If your parents play a significant role in the decision to attend SMI, have you discussed it with your parent(s)? If so, what was their response?
List any personal health concerns you may have.
Are you applying to any additional programs or fellowships this summer that run during the same time as SMI?*
- Yes
- No
If you are an upper level medical student, are you hoping to receive credit from your school as an away rotation for SMI (with an additional time, if needed, shadowing at Esperanza or doing SMI-related research)?*
- Yes
- No
How did you hear about SMI as an opportunity for your summer?*
References
Two letters of recommendation are required to complete the application, a personal and professional. The personal recommendation should be from someone who knows you well and can comment on the benefits of your participation in SMI. This could be a Bible study leader, pastor, close friend, SMI alum, etc. The professional recommendation should be someone who is familiar with your calling and abilities in the health professions. This could be a dean, professor, pre-med advisor, mentor in your field, family friend, etc. Although we don't have a set form for these, information that may be helpful to include is listed here: 1) in what context they've known you 2) how long they've known you 3) information and examples regarding your commitment to your faith (for personal reference, but only if applicable in the professional) 4) information and specific examples regarding any of the qualities you may have below (or others). For the personal recommendation, qualities to comment on may include accountability, integrity, compassion, correctability, perseverance, respect for others, listening skills, patience, humility, relational skills. For the professional reference, qualities to comment on may include workplace skills/aptitude/knowledge, work ethic, responsibility, correctability, punctuality, accountability, respect for others, relational skills/ability to work with others, dedication, creativity, initiative, etc. Please have your letters of recommendation sent directly to Holly Favino, Summer Program Director at [email protected] by 3/15/24 and by 2/15/24 for those applying early decision (email is preferable with contact address and phone included on the recommendation, but if necessary, may also be sent by mail to Holly Favino, c/o MCO, 1701 Delancey St, Philadelphia, PA 19103).
Personal Reference Name*
Personal Reference Phone Number*
Relationship*
Professional Reference Name*
Professional Reference Phone Number*
Relationship*
Short Answer Questions and Commitments
Briefly describe any relevant training opportunities you have had that may relate to your SMI participation (i.e. health care related jobs, cross-cultural exposure, ministry experience, etc).*
It is important that the applicant evidences an experience of personal salvation and progressive spiritual growth. Describe how you became a Christian answering the following questions: a) How and why did you commit your life to Christ? b) How has your relationship to Christ changed you and affected you on a daily basis, i.e., in your personal relationships, struggles, and decisions?*
Are you willing to submit to God's process of developing you in character and discipline?*
- Yes
- No
Are you willing to learn how to communicate Jesus Christ and the Gospel to others?*
- Yes
- No
Are you willing to be involved in intensive study and application of the Bible?*
- Yes
- No
Are you willing to participate fully in all scheduled project activities?*
- Yes
- No
What is your life vision or calling as you know it to be at this point?*
How do you envision your future career? Please be as specific as you can at the present time.*
Explain why you want to participate in the SMI this year and what you hope to see God teach you as a result of your involvement in the project? Again, please be as specific as possible.*
Due to the nature of the SMI, priority will be given to students who indicate that they plan to participate for the whole project. If you have a school or family commitment that must be honored or are in a wedding and you would still like to be considered, please indicate the date(s) you anticipate not being able to participate in SMI.
Instructions and Signature
1. All applications are subject to approval by the SMI Applications Committee. 2. If participating, you will be required to document that you have received three doses of Hepatitis B vaccine and are up to date on all vaccinations in order to participate in SMI. If you have not received this vaccine series or all necessary vaccinations, please begin to do so. Please include a copy of your COVID vaccine as well. In addition, in order for you to screen children during SMI, the program requires that you submit all state and/or federal child security clearances required (there may be as many as three documents). If you don't provide us with these you may still screen adults during the program (most of the screens performed during SMI are on adults). If you would like to screen children, please begin to collect the needed documents and/or contact the SMI director for more information. 3. Acceptance notices will be sent out no later than 4/1/2024. 4. Applying does not commit you to SMI. If accepted, you must return a confirmation form and non-refundable $150 deposit by 4/10/2024 to reserve your place. Checks can be made out to CCHF with SMI/MCO on the memo line or online payments may be available.
Typing your name below means you are electronically signing this application.*
Agreement Form
IMPORTANT. PLEASE READ THIS PAGE BEFORE YOU SIGN: What a person believes is the foundation for both life and ministry. The following are Christian tenets to which the Philadelphia Summer Medical Institute (SMI) leadership ascribes. If you disagree with any of these, please explain your differences on a separate sheet. 1. The Bible is inspired, authoritative; the Word of God. (2 Tim. 3:15-17) 2. There is one God, eternally existent in three persons: Father, Son and Holy Spirit. (John 10:30) 3. These are central truths of the Christian faith: The deity of our Lord Jesus Christ, His virgin birth, His sinless life, His miracles, His vicarious and atoning death through His shed blood, His bodily resurrection, His ascension to the right hand of the Father, and His personal return in power and glory. (Jn. 1:1-5; Phil. 2:5-11, 1 Cor. 15:1-6) 4. Believing in the person and work of Jesus Christ alone results in salvation; Jesus Christ is the only way of salvation. (Titus 3:4-7; Eph. 2:8-9; John 14:6; Acts 4:12) 5. The Holy Spirit's present ministry and indwelling enables Christians to live in fellowship with God. (Gal. 5:16-23; I John 1:3-4) The commitment of the Summer Medical Institute is “to serve and not to be served.” Serving in ministry means you sometimes submit to the needs of others even in areas of biblical freedom. Paul is a model of this (Romans 14 – 15:6). Serving with the SMI means you agree to the following: 1. I am willing to set aside personal preferences, habits and schedules to fulfill the ministry of the SMI. 2. I understand there are variations in practice and understanding of Scripture in some areas of Christian living. In serving with SMI, I will abide by the standards of the SMI in all areas including dress, entertainment, activities, etc. This includes a willing agreement to abstain from the use of alcohol, drugs, and tobacco for the duration of the SMI, and to be sensitive to cultural, regional, church and SMI expectations and standards. 3. I will seek to provide excellent medical screening to God’s glory and to present Jesus Christ as Lord and Savior. The student support for participating in the SMI 2024 is anticipated to be $1600 with housing provided (less the $150 deposit), which is tax deductible if you itemize deductions. Many students choose to raise support to cover this cost. If you choose to support raise, we can provide sample letters, forms and guidelines to help you. Please note: if you support raise, you are still responsible for the entire $1600. 1. If accepted to the SMI, I understand that I am responsible for the student participation cost, due June 11, even if I choose to support raise. I understand that this payment is required to participate in the SMI. 2. I understand that there is a non-refundable $150 deposit due when I submit my acceptance letter. Checks should be mailed and made out to Medical Campus Outreach and with SMI Philly/MCO on the memo line. This amount will be deducted from the $1600 participation cost. Please include a note saying who the deposit is for. 3. I understand that if I choose to support raise and receive more than $1600 in donations, any excess in donations will be used for other expenses of the SMI program that are not covered by the student participation amount, and cannot be refunded. All participant donations, whether student deposit or support fundraising, become the restricted assets of Christian Community Health Fellowship (CCHF) and designated for Medical Campus Outreach Philadelphia (MCO). MCO and SMI Philadelphia are ministries of CCHF. 4. I understand that I cannot support raise for my personal expenses outside of my needed costs for participation in SMI.
Typing your name below means you are electronically signing this agreement.*