The Leukemia & Lymphoma Society Underrepresented Minority (URM) Medical Student Research Program Interest Form

Thank you for your interest in The Leukemia & Lymphoma Society's Underrepresented Minority (URM) Medical Student Research program. This program will provide students with the opportunity to spend a year immersed in hematology/oncology research and increase knowledge of blood cancer.

The information you provide is for internal use only, to help gauge interest in the program and aid in screening applicants. Required responses are denoted by an asterisk. After submission, someone will be in touch with you to discuss next steps in the application process. Thank you!

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Preferred Phone Number *

Preferred Email Address *

Confirm Email Address *

Medical School Name and Address *

Anticipated Year of Graduation *

Race & Ethnicity (Choose all that apply) *

Black or African American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Hispanic or Latino(a)

Date of Birth (MM/DD/YYYY) *

Are you a US Citizen or Permanent Resident and reside in the US or a US Territory? *

What is your gender identity?

How did you hear about this program? *

What is the best day/time to reach you? *

Please upload a current CV or resume *