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1 MARQUETTE UNIVERSITY HEALTH CAREERS OPPORTUNITY PROGRAM College Science Enrichment Program (CSEP) & Pre-Enrollment Support Program (PESP) Website: INSTRUCTIONS: Please type or print clearly in black ink. Complete all sections of application. Our early acceptance date is March 1 of current school year. We will continue to accept applications until the program is full. Return the application to the address indicated at the end of the application. Application checkoff list: Complete application below. Include a copy of your parents latest tax return (1040 or 1040A tax forms) and a copy of your latest tax return. Note: If you are at least 24 years old and have not been claimed as a dependent on your parents tax return for three years, then parent tax data and returns are not required. Send an official copy of your transcripts. Send two recommendation forms. One must be completed by your science professor ( ed directly to or mailed to the address indicated at the end of the application). Write a personal statement explaining why you want to pursue a health care career. Also describe your volunteer and service work with disadvantaged populations. If you are not a U.S. citizen proof of residency is required (i.e. Permanent Resident Card/Green Card or passport). APPLICANT INFORMATION First Name: Middle Initial: Last Name: Social Security #: of Birth: Gender: M / F Current Address I will only be at this address until / / Street Address: City: Permanent (Parent s) Address Street Address: City: State: Zip: State: Zip: Area Code: Phone: Area Code: Phone: Most frequently utilized address: ACCOMODATIONS Do you have any Physical Disabilities that necessitates specifically designed instructional materials or programs, modified physical facilities, or related services to enable full participation in and access to the program? Yes No If yes, Specify: If space is insufficient feel free to attach additional document regarding request for accommodations. CITIZENSHIP What city and state/country are you originally from? Citizenship: US Citizen Permanent Resident Alien # Non-Resident Alien If you are not a US citizen proof of residency is required (i.e. Permanent Resident Card/Green Card or passport) 1

2 1 = American Indian or Alaska Native 2 = Asian (Specify): 3 = Black or African American 4 = Hispanic or Latino (Specify): ETHNIC/RACIAL IDENTITY Please check one 5 = Native Hawaiian or other Pacific Islander 6 = White 7 = Unknown PROGRAM OF INTEREST Please select one area of interest. 8 = Other (Specify): Behavioral Health Biomedical Sciences Clinical Laboratory Sciences Clinical Mental Health Counseling Dentistry Human Movement Science/Exercise Physiology Medicine Occupational Therapy Physical Therapy Physician Assistant Studies 1. Name of Current College/University: ACADEMIC INFORMATION Please list all colleges and universities attended. Current Year in School: FR SO JR SR Other Expected Graduation (mo./year): / Current GPA (Cumulative): GPA (Science) Grading Scale (Please Check): 4.0 Other: 2. Name of College/University: Year in School: FR SO JR SR Other Expected Graduation (mo./year): / 3. Name of College/University: Year in School: FR SO JR SR Other Expected Graduation (mo./year): / Have you taken courses in biology or chemistry? Yes No List Biology courses taken: List Chemistry courses taken: 1. Name of High School: Address Please list last high school attended. Biology: Chemistry: Please list the high school biology or chemistry courses you have taken: 2

3 TEST SCORES Please list scores and attach a copy of your score report to your application. DAT Have you taken the Dental Admissions Test (DAT)? Yes taken? No Planning? Academic Avg. PAT Avg. Quant Reason. Reading Comp. Bio. Inorganic Organic Sci. Avg. Have you taken a DAT review course? Yes No If yes, where? GRE Have you taken the Graduate Record Examination? Yes take? No Planning? Verbal Quant. Analytical MCAT Have you taken the Medical College Admission Test? Yes take? No Planning? Chemical & Physical Foundations of Biological Systems Critical Analysis & Reasoning Skills Biological & Biochemical Foundations of Living Systems Psychological, Social & Biological Foundations of Behavior Total PARENT INFORMATION Parent 1 / Guardian s Name: Please check the highest level of degree obtained: GED/High School Diploma Degree Held: Associate s Bachelor s Master s Doctoral Other Occupation: Employer: Parent 2 / Guardian s Name: Please check the highest level of degree obtained: GED/High School Diploma Degree Held: Associate s Bachelor s Master s Doctoral Other Occupation: Employer: HCOP OUTREACH How did you hear about our program? Ad Counselor Friend Website Other Source s Address: City: State: Zip: REFERENCES List names and titles of two individuals who will complete your HCOP Recommendation Forms. Applicant must submit at least one academic recommendation (teacher or faculty). Please do not list relatives and friends as references. Name Phone: ( ) Title Best time to contact: address (optional) Name Phone: ( ) Title Best time to contact: address (optional) 3

4 ELIGIBILITY Please review the sections below to determine your eligibility for HCOP. You must be educationally and financially disadvantaged to be admitted into CSEP or PESP. Educationally Disadvantaged: You must meet at least one of the educational markers below. Check all that apply. First generation college student Attended high school in Milwaukee Public Schools or Chicago Public Schools Attended high school in a rural area (city population below 10,000) Below average academic performance needed (i.e. GPA, test scores) for admission into intended health profession program You have an extreme personal, social, family, or environmental circumstance that you would like to explain in your personal statement Financially Disadvantaged: Family adjusted gross income must be at or below 200% of the federal poverty guideline for a student s family size to be admitted into HCOP programs. If you are 24 years old or older and have not been claimed on your parents tax returns within the last three years, then your parents income information or tax returns are not required. What was your family s Adjusted Gross Income (AGI) reported in your parents federal income tax form 1040 or 1040A for last year? $ Dependents reported on income tax return? What was your Adjusted Gross Income as reported in the federal income tax form 1040 or 1040A for last year? $ Dependents reported on income tax return? Please review the 2016 Federal Poverty Chart on the right to see if you are financially disadvantaged. (Highlight the row that applies for your family) 2016 Federal Poverty Chart 200% of Poverty Guideline (AGI reported on 1040 form) 1 $23,760 2 $32,040 3 $40,320 4 $48,600 5 $56,880 6 $65,160 7 $73,460 8 $81,780 Persons in Household (Dependents reported on 1040 form) For families greater than 8 persons, add $8,320 per person PERSONAL STATEMENT 1. Write a personal statement explaining why you want to pursue a health care career. Attach your typed personal statement (1 page single spaced) to your application package. 2. Describe your volunteer and service experience working with disadvantaged populations. Attach your typed response with your personal statement. 3. Have you ever participated in a health careers program (i.e. health club, internship, externship, mentoring, shadowing)? If yes, please indicate the program name, sponsor, dates, and state in a short paragraph. Attach your typed response with your personal statement. 4. (Optional) List any personal, family, social, school or environmental challenges that you have faced that might have negatively impacted your life? Attach your typed response with your personal statement. 4

5 VERIFICATION STATEMENT I certify that the above information is true, complete and correct to the best of my knowledge. I understand that falsifying or providing incorrect information may jeopardize my participation in this or future Marquette University Health Careers Opportunity Programs. Student Signature Parent/Guardian Signature (If student is under age 18) To be completed by the student: INFORMATION RELEASE I, (printed name), am applying for admission to Marquette University Health Careers Opportunity Program. I am aware of the provisions of the Family Educational Rights and Privacy Act and hereby authorize the release of the requested information directly to Marquette University Health Careers Opportunity Program (i.e. transcript, recommendation forms, etc.). I realize that I may not view some of the information requested, for example, recommendation forms. I understand that Marquette University will also maintain records of my performance in program activities and that they will track my academic progress after the summer program when I return to school. I authorize Marquette University access yearly transcripts until I graduate from college. I agree to the release of this information to Marquette University staff members. Student Signature Parent / Guardian Signature (If student is under age 18) Marquette University does not discriminate on the basis of race, national origin, gender age, religion or disability. Please mail your form directly to the following address: Marquette University Health Careers Opportunity Program Schroeder Health Complex, 346 PO Box 1881 Milwaukee, WI OR Fax: (attention HCOP) 5

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