2016 Stanford Medicine X Student Leadership Application

Applicant Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Current school and degree program*

Please state your current school and degree program (MD, PhD, RN, etc...) Please note, applicants must be enrolled as a full-time student at an accredited degree-granting academic institution.

Photo

Why do we need this? If you win a scholarship, we would like to recognize your accomplishment on our Medicine X website. By uploading your photo, you agree to give us permission to use it on our website. We will also need your photo to create an ID badge for the conference.

Please Upload your Photo*

Please upload a digital photo of your face for use by Medicine X on our website and on your ID badge in the event that you are awarded a scholarship. (JPEG, PNG, GIF are all acceptable formats).

Conference Attendance

Are you able to attend all days of the Medicine X conference?*

We expect students in the Student Leadership program to attend all days of the conference, September 16-18, 2016.

Yes. I can attend all days.
No, I have an issue that prevents me from attending all days.

If you answered "No" above, please explain why you cannot attend all days of the conference.

Scholarship Track Preferences

Please indicate to which Student Leadership Track(s) you wish to apply.*

*Please refer to the Medicine X Student Leadership program page for more information about the different tracks.
Please answer the subsequent questions that correspond to the track you're interested in. You may apply to both the Engagement & Producer and Presenter track, however, conference participation is limited to one track per student.

Engagement & Producer
Presenter

Engagement & Producer Track Questions

Description: The purpose of the Engagement & Producer Track is to provide an opportunity for students to attend Stanford Medicine X and interact—both in-person and through social media—with conference attendees and the world-at-large. Students accepted to the Medicine X engagement/producer track will be paired with ePatient scholars from the ePatient engagement/producer tracks and will participate in a collaborative design challenge.

Selection Criteria: Successful applicants will demonstrate a history of student community engagement, outreach and advocacy, with preference for individuals using emerging technologies such as blogs, Twitter, and social media to pursue these goals.

Please tell us why you are interested in the engagement track and how you would use this opportunity to engage with the Medicine X audience and the world at large. If you consider yourself a producer, please tell us what content you would create during the conference and how would you share it with the world?*

Presenter Track Questions

Description: The purpose of the presenter track is to provide an opportunity for students to attend and speak at the Stanford Medicine X. By providing a student voice to the proceedings, participants will help share and disseminate the knowledge to educate and inspire others.

Selection Criteria: Applicants will be asked to submit a speaking proposal that describes their story and what they would like to speak about. Student talks in the presenter track will be five minutes in length and follow a pecha kucha/Ignite! format.

Please describe the five minute talk you would give as a student presenter on the Medicine X main stage. Please provide an summary or outline of your talk.*

Examples of previous topics include:

• How do you consider yourself an engaged health care provider?
• How do you see yourself working together in partnership with patients?
• How does technology enable you to care for your patients?

General Applicant Questions

Diversity Health Innovation Empathy Learning Education
Patient Respect Future Design Technology Challenge
Community Inclusivity Engagement Leadership Stakeholders

Pick 3 words from above and tell us what they mean to you.*

Describe a current challenge you're facing as a student pursuing a career in health care, and propose a solution, or how you've solved it.*

For example, classroom vs. real practice, silos in health care, lack of interdisciplinary education, underuse or overuse of technology.

Tell us a past example of how you engaged the community as a student*

What do you hope to learn from your Medicine X experience? Specifically, how will this help you achieve your long-term goals?*

Consent to Contact

I agree to allow Medicine X to contact me by email about the conference. (We are a non-profit conference and may on rare occasion send information we think will be of interest to you on behalf of our partners)*

Yes
No