FIT Application Form

Name:*

First Last

Preferred first name/nickname (as you would like it on your badge should you be accepted to the program):

Degree(s) earned (e.g., MD, MPH):*

Institutional/work email:*

Personal email:*

Please include an additional (e.g., non-institutional) email address you may be reached at

Preferred email for FIT communications:*

Cell phone/personal telephone:*

Fellowship Information

Fellowship program name:*

Institution*

Specialty (e.g., infectious disease, adolescent, GI, medical toxicology, etc.):*

Fellowship program address:*

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

Fellowship program medical school affiliation, if any:*

Write N/A if there is none.

Fellowship program hospital affiliation, if any:*

Write N/A if there is none.

Which year of your fellowship will you be in as of April 2027?*

Please describe "other":

What is the total length of your fellowship? (e.g., 2 year, 3 year, 4 year total)*

Percent of time available for research:*

Mailing Address

Same as above?*

Yes
No

Mailing address:

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

Faculty Mentor and Program Director Information

Faculty mentor name:*

Faculty mentor email:*

Is your faculty mentor the same as your fellowship program director?*

Yes
No

Fellowship program director name:

Note: if you have already provided the fellowship program director's information above, you may leave these fields blank.

Fellowship program director email:

Other Information

Gender Identity*

If you selected "Prefer to self describe," please specify:

Pronouns

If you selected "Prefer to self describe," please specify:

Race/ethnicity:*

Black or African American
American Indian or Alaska Native
Asian
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other

Select all that apply.

Please describe "other":

Have you ever visited the following in a professional context? (Check all that apply.)

A mutual help or 12-step program (e.g., AA, NA, Learn to Cope)
A substance use treatment facility only (e.g., detox, methadone maintenance)
A harm reduction program (e.g., syringe service, naloxone distribution)

Preferred T-shirt size (should you be accepted to the program):*

What are your plans upon completion of your fellowship? (Check any or all that apply)*

Clinician Educator
Research
Full-time Clinical Practice
Academic Medical Center Practice
Private Practice
Other

Please describe "other":

How did you hear about the FIT Program?*

Faculty at my institution
Brochure or postcard advertising the program
Internet search
Email from FIT Program
Other (describe below)

Please describe "other":

Please specify:

Application Essays

Please provide a personal statement of 500 words or less describing your motivation and goals for participating in the FIT Program. Relate your interest in addiction medicine and research to your previous training, fellowship plans, your career aspirations, and how you will apply the knowledge gained at the FIT Program. Copy-paste this into the box below.*

Please include a description of no more than 300 words describing a research project idea that incorporates addiction medicine and that you could undertake during your fellowship. This description should include the project aims, research question, methods and potential implications. Please upload your statement with NAME and DATE in the header as a PDF here.*

Max. file size: 100 MB.

Curriculum Vitae

Please upload your curriculum vitae (CV) as a PDF.*

Accepted file types: doc, pdf, Max. file size: 100 MB.

16th Annual Fellow Immersion Training (FIT) Program: Fellow Application

Fellowship Information

Mailing Address

Faculty Mentor and Program Director Information

Other Information

Application Essays

Curriculum Vitae