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PRIORITY DEADLINE: Tuesday, January 31, 2012, 12:00 midnight Pacific time
FINAL DEADLINE: Sunday, March 4, 2012, 12:00 midnight Pacific time

Thank you for your interest in the Summer Institute for Medical Students program. Before you begin this application, please be sure to gather all required information including your response to the essay question and your Curriculum Vitae. Application questions may take an hour or more to complete and a partially completed application cannot be saved for later. Incomplete applications will not be submitted and candidates may not apply more than once per year.

In addition to completing the form on this page, two letters of recommendation are required. Please see "Upload your Letters of Recommendation" for instructions.

Please note that we will begin to fill the limited number of program seats available immediately following the PRIORITY application deadline on January 31, 2012 at midnight, Pacific time. To be considered for a remaining seat, if any, applications will be accepted until March 4, 2012 at midnight, Pacific time. No applications will be accepted after the final deadline.

Applicants and alternates invited to participate in the program will be notified by e-mail by March 31, 2012. Applicants who are not selected will be notified by April 6, 2012.

For additional information about the program, please see our FAQ.  

Title Select One Mr. Mrs. Ms. Dr.
First Name	Middle Name	Last Name
Gender Select One Male Female	Date of Birth	SSN
		I do not have a Social Security Number
Marital Status Select One Single Married Divorced
Address	City	State Select One AB AK AL AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NH NJ NL NM NT NS NU NV NY OH OK ON OR PA PE QC RI SC SD SK TN TX UT VA VT WA WI WV WY YT Zip
Country	Home Phone	Cell Phone
E-mail Address	School Name	Year in School Select One Freshman Sophomore Junior Senior Post-Graduate
State of School Select One AB AK AL AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NH NJ NL NM NT NS NU NV NY OH OK ON OR PA PE QC RI SC SD SK TN TX UT VA VT WA WI WV WY YT

Contact in Case of Emergency:

Name	Relationship	Phone Number
Phone Type Select One Cell Work Home
Name	Relationship	Phone Number
Phone Type Select One Cell Work Home

Do you have involvement with chemical dependency?    Personal       Professional

Please Explain

Previous Training in the Chemical Dependency Field

Please mark all dates you are available and indicate your session preferences below. 2012 dates are as follows:

May 21-25 (05/21/12) June 4-8 (06/04/12) June 18-22 (06/18/12) July 2-6 (07/02/12) July 16-20 (07/16/12) July 30 – Aug 3 (07/30/12 – 08/03/12) August 13-17 (08/13/12)

1st Choice

2nd Choice

I agree to the following statements: 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.

Curriculum Vitae: (PDF only)

Two letters of recommendation to Betty Ford Institute*: (PDF only)

Essay**: (PDF only)

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Press only once! It may take time to upload the attached files

*Letters of recommendation should be addressed to "SIMS Program Director" and describe why you are a good candidate to participate in the SIMS program. If the person writing the letter wants to send it under separate cover, please be sure your full name and date of birth are referenced in the letter (so we may match it to your application). Please e-mail letters to education@bettyfordinstitute.org or send via post to Betty Ford Institute SIMS Program, P. O. Box 1560, Rancho Mirage, CA 92270.

**Your essay should be one page typed (about 500 words) and describe one or more of the following, - In your own words, explain the definition of addiction. - How has addiction personally affected your own life? - What do you hope to achieve by participating in the SIMS program?

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