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Fellowship Application
Evelyn J. Mackin Hand Therapy Fellowship
Additional Information and Application
Sponsored by:
Hand Rehabilitation Foundation
The Philadelphia Hand Center, P.C.
College of Health Professions, Thomas Jefferson University
North Coast Medical, Inc.
The deadlines for complete submission
are October 15,
2011 for the January 2, 2012 start date, and March 15, 2012 for the July 1, 2012 start date.
The Fellow will be notified no later than October 15, 2011 for the Januaryy
2, 2012
start date and May15, 2012or the July 1, 2012 start
date.
Checklist for Processing Application
_____Updated curriculum vitae/resume including continuing education courses attended
_____Completed Application
_____Personal statement which describes your interest in hand rehabilitation, i.e., how you became interested and why; short- and long-term career goals; expectations of this fellowship; your self-evaluation in terms of strengths and weaknesses with regard to hand therapy knowledge and skills. Please discuss potential plans to use hand therapy knowledge and skills to benefit underserved populations. Kindly limit your statement to 2-3 pages.
_____Case description of a patient with a hand injury or condition that you have treated which stimulated your interest or presented a challenge. Indicate how you handled the case.
_____Three letters of recommendation from persons whose relationship with you has been in an academic or professional setting.
_____Academic transcripts from
professional education
(Request these ASAP. A form is
included for Thomas Jefferson University graduates.)
_____Examples of volunteer activities in hand therapy (if no employment experience)
Application for the Evelyn J. Mackin Hand Therapy Fellowship
Name
_________________________________________________________________________________
(Last)
(First)
(Middle)
(Credentials/Degree)
Current Mailing Address___________________________________________________________________
_______________________________________________________________________________________
Permanent Address______________________________________________________________________
_______________________________________________________________________________________
Telephone______________________________________________________________________________
(Work)
(Home)
(Facsimile)
January 2, 2012 through June 30, 2012 _________
July 1, 2012 through December 31, 2012 ________
Age___________ Date of Birth_____________Sex_____________Social Security#___________________
Marital Status___________________________________________________________________________
Name and Address of Spouse______________________________________________________________
If not married, please indicate name and phone number of person to
be contacted
in case of emergency_____________________________________________________________________
Are you a United States Citizen?_______________ If not, citizen of what country?___________________
Type of Visa on which you have entered/will enter the United States_______________________________
Educational_________________Immigrant________________Other (Please Specify)_________________
Please indicate need for any special accommodation_________________________________________________________________________
______________________________________________________________________________________
Current work status: Full-time_______________________ Part-time_____________________________
Occupational Therapist____________________________ Physical Therapist________________________
Name of Employer________________________________________________________________________
Address________________________________________________________________________________
Telephone______________________________________________________________________________
Number of Years Professional Experience____________________________________________________
Membership(s) in Professional Organizations (i.e., AOTA, APTA, ASHT)
Please describe your experience with hand and upper extremity diagnoses and procedures
What percentage of your total work experience has consisted of hand patients?
0%_____ 25%_____ 50%_____ 75%_____ 100%____
Please describe your learning style
How many patients are you comfortable treating each day?
Please state why you think you are a good candidate for the Evelyn J. Mackin Fellowship