Application for the UB Pharmacy Summer Institute (PSI)

Submit this form to apply for the University at Buffalo School of Pharmacy and Pharmaceutical Sciences Pharmacy Summer Institute (PSI). The deadline for receipt of applications and supporting documents is May 1.

About the Applicant

Email Address

First Name

Preferred Name

Middle Name

Last Name

Birthdate

Mobile Phone Number

Legal Sex (Optional)

Female

Male

Gender Identity

Pronouns

Are you Hispanic?

Yes

No

Race

Country of Citizenship

Mailing Address

Country

Street

City

Region

Postal Code

Parent/Legal Guardian Information

Parent/Legal Guardian Email Address

Parent/Legal Guardian First Name

Parent/Legal Guardian Last Name

Parent/Legal Guardian Mobile Phone Number

Emergency Contact Information

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Email Address

Emergency Contact Mobile Phone

Primary Physician Contact Information

Primary Physician First Name

Primary Physician Last Name

Primary Physician Phone Number

Allergies, Medical Conditions or Dietary Restrictions (type "none" if not applicable)

Applicant Educational Information

Applicant Type

Middle School

High School

Current UB Student

College Student

Middle or High School Name

Middle or High School CEEB Code

Undergraduate Institution

Major (required for college students)

Current Grade Point Average

Transcript

Upload an unofficial student transcript (not required for UB students)

Recommender Information

Upon submission of this application, emails will be sent providing instructions to the recommender for submitting a letter. Be sure to inform and remind them to check any spam/junk email folders if the instructions for submission have not been received.

UB SPPS pre-pharmacy and pre-pharmaceutical sciences students should list Sara Robinson, Academic Advisor (smeskill@buffalo.edu) as their recommender.

We will not accept letters of recommendation received directly from applicants. By submitting this information, applicants waive any rights to view these confidential letters.

Recommender

First Name

Last Name

Email Address

Additional Information

Describe your interest in pharmacy

List any extra-curricular activities, honors and awards

First Name Phonetic Pronunciation

Last Name Phonetic Pronunciation

Photo Release Form

I consent to and authorize the use of any and all photographs, images, videotapes, audiotapes, electronic digital recordings, or electronic transmissions made of me by the University at Buffalo School of Pharmacy and Pharmaceutical Sciences (SPPS) personnel or the designees of SPPS for the purposes of publication, display, broadcast (print, web, digital display and all other forms of media, including social media), or to use in the SPPS instructional program, the instructional programs of other institutions as authorized by SPPS, or in SPPS scholarly works. I agree that such interviews, recordings, articles, quotes, photographs, images, films, audio or video or digital recordings, and/or any reproductions of same in any form are the property of the University at Buffalo and I relinquish any present or future claim for reimbursement for said photographic or film reproduction of my likeness or for the said testimonials by me. I hereby release the University at Buffalo, its affiliates, employees, representatives and agents from any and all claims, demands, costs, and liability that may arise from the use of these interviews, recordings, photographs, videotapes or films, and/or any reproductions of same in any form, as described above, arising out of being interviewed, recorded, photographed, videotaped or filmed. I acknowledge I have read this consent form in its entirety, or it has been read (or translated) to me, and I have had the opportunity to ask questions about it and understand it. Please alert the photographer if you do not wish to have your photograph taken.

Photo Release Consent Form

Yes, I consent to the photo release form conditions

No, I do not consent release

Transportation Release Consent Form

While participating in SPPS Pharmacy Summer Institute, students may take field trips. When these excursions occur, students will travel off of the University at Buffalo’s South Campus. Transportation will be provided by the Institute to and from the sites. I give permission for my student to travel off of the University at Buffalo’s South Campus during the duration of the above Institute via the transportation provided by the Institute. I assume all risks and hazards and hereby waive, release, absolve, indemnify and agree to hold harmless the University at Buffalo – State University of New York and SPPS Pharmacy Summer Institute, as well as its directors, officers, administrators, employees, or other agents from any and all liability, actions, lawsuits, claims, demands and expenses resulting, directly or indirectly, from loss of life, personal injuries, property damage, or other damage suffered by my Institute participant while traveling to or from off-campus sites.

Transportation Release Consent Form

Yes, I consent to the transportation form conditions

No, I do not consent

By typing your name and date on this document, you are electronically signing this document and you agree your electronic signature is the legally binding equivalent to your handwritten signature, and you are also confirming that you are the individual named in the electronic signature, and that you are authorized to sign this document.

Student Signature (enter first and last name)

Today's Date

Parent Signature (enter first and last name)

Today's Date

UB does not have a policy that limits or favors current UB students, transfer or out-of-state applicants. All applicants are considered equally. UB SPPS is committed to a nondiscriminatory admission policy and philosophy. In accordance with federal and state laws, no person, in whatever relationship with the University at Buffalo, shall be subject to discrimination on the basis of age, religion or creed, color, disability, national origin, race, ethnicity, sex, marital or veteran status. Learn more about our Non-Discrimination Policy The faculty of the UB SPPS have established Personal Attributes and Capabilities Essential for Admission, Progression, and Graduation (Technical Standards) for our Doctor of Pharmacy Degree. Learn more about Technical Standards for Admission Requirement. Questions regarding accommodations should be emailed to pharm-admit@buffalo.edu no later than June 2.

PHAR Population (hidden)

Yes

No