UNDERGRADUATE HEALTH SCIENCES ENRICHMENT PROGRAM PROGRAM DATES: JUNE 5, 2017 JULY 14, 2017

Transcription

1 UNDERGRADUATE HEALTH SCIENCES ENRICHMENT PROGRAM PROGRAM DATES: JUNE 5, 2017 JULY 14, 2017 APPLICATION DEADLINE: 5:00PM, MONDAY, MARCH 20, 2017 The Undergraduate Health Sciences Enrichment Program (UHSEP) is a six-week, academically rigorous residential program at the University of New Mexico (UNM) that provides an academic learning environment for entering college freshmen who are interested in a career as a health professional. The program will challenge students with a rigorous curriculum in academic, social, and developmental support. Interested applicants must be New Mexico residents, as defined by the University of New Mexico Preferably, underrepresented in medicine and come from economically and/or educationally disadvantaged backgrounds. Applicants should demonstrate a commitment to increasing health equity. Due to payment purposes, applicants accepted in to our HEALTH NM pipeline programs must have a Social Security Number (SSN) or Individual Tax Identification Number (ITIN). Questions regarding citizenship, residency and/or application details can be directed to HSC-diversity@salud.unm.edu or by calling or toll free Student Eligibility NM Resident Minimum GPA of 2.5 on a 4.0 scale Incoming College Freshmen Have been accepted to and entering a post-secondary college/university Participation Dates All accepted student participants are required to attend the program orientation on Saturday, May 6 th, The program will begin on Monday June 5, 2017 and end on Friday July 14, Student participation is expected throughout the duration of the program; participants will be required to stay on campus unless otherwise indicated during the specified time. If accepted into UHSEP, the Office for Diversity will send all participants an acceptance packet that must be completely filled out and returned to our office no later than Saturday, May 6, However, we ask for accepted participants to confirm their participation in writing via no later than Friday, April 21, Failure to include any of the supporting documents, not following directions completely, or leaving blank sections on this application form will result in an automatic disqualification. Additionally, failure to meet the March 20, 2017 deadline will result in automatic disqualification. To apply, please complete the attached application. Accepted participants need to submit proof of their post-secondary college acceptance. ALL COMPLETED APPLICATIONS MUST BE SUBMITTED IN PERSON BY 5:00 PM OR POSTMARKED ON MARCH 20, FAXED APPLICATIONS WILL NOT BE ACCEPTED. SUBMIT COMPLETE APPLICATION BY MARCH 20, 2017: Apply Online at: Mail to: UNM HSC Office for Diversity MSCO University of New Mexico Albuquerque, NM Deliver in person to: UNM Health Science Center, UNM North Campus Office for Diversity Health Sciences and Services Building, Suite 102 Building #266, Campus Map UHSEP Application Revised 1/26/17

2 UNDERGRADUATE HEALTH SCIENCES ENRICHMENT PROGRAM PROGRAM DATES: JUNE 5, 2017 JULY 14, 2017* APPLICATION CHECKLIST APPLICANT NAME: Complete application packets must include: Complete Student Application High School Transcript(s): An unofficial copy of your high school transcript Two Completed Recommendation Forms One form should be completed by someone who can evaluate your character and academic performance, such as a professor, teacher, counselor, principal, mentor, employer, or volunteer supervisor. The second form can be from someone of your choosing. Forms must be in a sealed envelope with the writer s signature across the seal on the back of the envelope. ACT or Pre-ACT Scores (if applicable): include a copy of your exam score(s), if not listed on your transcript(s) Personal Statement: (The personal statement must be typed, double-spaced, 12-point font, Times New Roman, 1 margins, and no more than 2 pages.) Please state your purpose in applying to this program. In this personal statement, we are seeking to capture not only a snapshot of where you are currently as a student but also where you have been and where you see yourself in the future as a health professional. Relevant factors include but are not limited to the following: Achievements you have accomplished despite of educational, social, and economic challenges. What in your personal, work, or academic background has motivated your interest in a health career? What are your educational goals and in what ways will they impact you, your family, and your community? What kind of educational experiences and skillsets do you hope to gain this summer that will best assist you in reaching your career goals and dreams? Note: Only two recommendation letters will be reviewed. Incomplete applications will not be considered. It is your responsibility to confirm that we have received all your materials. Be sure not to leave any fields blank. Office Use Only Date Submitted: Staff Initials: UHSEP Application Revised 1/26/17

3 PERSONAL INFORMATION UNDERGRADUATE HEALTH SCIENCES ENRICHMENT PROGRAM STUDENT APPLICATION Please make sure that the information given in this section is accurate and matches with any federal or state issued document (ex. Social security card, ITIN card). 1. Name: Last First Middle 2. Address: Street Address or P.O. Box Number City or Town County State Zip Code 3. Phone: Address: 4. Gender: Female Male 5. U.S. Citizen: Yes No If no, can you provide a SSN or ITIN: Yes No 6. New Mexico Resident: Yes No If no, state of residency: 7. Date of Birth: 8. Place of Birth: 9. Do you consider yourself to be Hispanic/Latino(a)? Yes No In describing yourself, please select one or more of the following racial categories: American Indian or Alaskan Native (Specify affiliation): Asian Black or African American Native Hawaiian/Pacific Islander White Other (Please specify): 10. What language(s) do you speak? What is the primary language spoken at home? What was your first language? EDUCATIONAL BACKGROUND 11. High School Name: 12. Address: Street Address or P.O. Box Number School District City or Town County State Zip Code 13. Current Grade Level: 14. Cumulative Grade Point : 15. Have you taken any dual credit classes? Yes No If answered yes, what university/college did you attend? 16. Have you taken any advanced placement classes? Yes No If answered yes, what classes did you take? 17. Please list the post-secondary college(s) to which you have applied or been accepted to (proof of acceptance is required for at least one of them): Name of Institution City and State Orientation Date UHSEP Application Revised 1/26/17

4 FAMILY BACKGROUND Parent/Guardian 1 (Required): Applicant lives with this parent/guardian: Yes 18. Name: No Last First Middle 19. Address: Street Address or P.O. Box Number City or Town County State Zip Code 20. Phone: Address: 21. What is the highest level of education completed by Parent/Guardian 1: 8 th grade or less Trade/vocational school Master s degree Some high school Associate s degree Doctoral/Professional degree High school diploma/g.e.d. Bachelor s degree Not sure Some College 22. If Parent/Guardian 1 obtained an Associate s degree or higher, when did they start (mm/yyyy)? When did they complete their degree (mm/yyyy)? Parent/Guardian 2 (Required): Applicant lives with this parent/guardian: Yes 23. Name: No Last First Middle 24. Address: Street Address or P.O. Box Number City or Town County State Zip Code 25. Phone: Address: 26. What is the highest level of education completed by Parent/Guardian 2: 8 th grade or less Trade/vocational school Master s degree Some high school Associate s degree Doctoral/Professional degree High school diploma/g.e.d. Bachelor s degree Not sure Some College 27. If Parent/Guardian 2 obtained an Associate s degree or higher, when did they start (mm/yyyy)? FINANCIAL BACKGROUND 28. I am currently financially supported by (check all that apply): When did they complete their degree (mm/yyyy)? Self Father Mother Other (state relationship to you): 29. Total Annual Household Income: 30. How many people live in your household (include yourself)? 31. What is the number of dependents under the age of 18 in your household: ADDITIONAL INFORMATION 32. Have you completed any other UNM HSC Office for Diversity programs (check all that apply)? Dream Makers/Dream Makers + HCA STEAM-H Career Exploration Extravaganza Pre-college Math & Science Program 33. Do you have any relatives in a health profession? Yes No Which specific fields? UHSEP Application Revised 1/26/17

5 34. How did you find out about this program? Instructor, Advisor Web Publications (websites, listserv) Office for Diversity Friend, Parent Flyer/brochure Other (specify): 35. Please list your health career interest(s): 36. Please list any health related certifications or training you have received and date of completion (i.e. CPR, First Aid): 37. Please list extra-curricular, volunteer, and/or community experiences: (i.e. sports, school clubs, church activities, etc.) 38. Do you have any other obligation during the program Participation Dates that may interfere with your ability participate in this program? Yes No If answered yes, please include information and dates for things such as (but not limited to), anticipated travel, employment, college orientation, etc. 39. If applicable, please list any special needs, accommodations, and/or considerations you would like us to be aware of during your participation in the program: STATEMENT OF CERTIFICATION I certify that all information given is true to the best of my knowledge. I understand that failure to disclose accurate information is grounds for dismissal from or selection into the program. I agree to provide all necessary documentation. Signature of Applicant Date Signature of Parent/Guardian (If under age 18) Date UHSEP Application Revised 1/26/17

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7 RECOMMENDATION FORM PLEASE RETURN THIS WITH YOUR APPLICATION To the Applicant Please fill in your name and high school on the lines below and give this information to the individual you have selected provide a recommendation for you. Applicant s Name To the recommending individual The student named above is applying to the UNM Health Sciences Center, Office for Diversity s Undergraduate Health Sciences Enrichment Program. This program provides an academic learning environment for entering college freshmen that are interested in a career as a healthcare professional. The program will challenge students with a rigorous curriculum in academic, social, and developmental support. This program seeks to identify students who demonstrate the following characteristics: Financial need; Academic performance or promise; Interest in pursuing a health-related career; Strength of character, evidence of leadership potential, and emotional maturity and stability; The potential to contribute to one s community later in life. Please provide your contact information below, in the case that the Office for Diversity staff has any pending questions or concerns. Recommender Name: Phone Number: Relationship to Applicant: To help in the selection of participants into the Undergraduate Health Sciences Enrichment Program, we ask that you please answer all of the following questions. Please limit your answers to the allotted space provided. ALL COMPLETED RECOMMENDATION FORMS MUST BE SUBMITTED IN A SEALED ENVELOPE TO THE STUDENT PRIOR TO THE APPLICATION DEADLINE OF MONDAY, MARCH 20, How long and in what capacity have you known this applicant?

8 Please describe the applicant s strengths? Please comment on the applicant s area(s) of development. What efforts has the applicant made to improve? How has the applicant contributed above and beyond her/his expected responsibilities? Please use the following space to include any additional comments. (Optional) Please rate the applicant on the following categories: Cannot Recommend Below Above Excellent Academic Performance Leadership Qualities Emotional Maturity Reliability Ability to interact with adults and peer Professionalism Resiliency (Ability to overcome barriers)

9 RECOMMENDATION FORM PLEASE RETURN THIS WITH YOUR APPLICATION To the Applicant Please fill in your name and high school on the lines below and give this information to the individual you have selected provide a recommendation for you. Applicant s Name To the recommending individual The student named above is applying to the UNM Health Sciences Center, Office for Diversity s Undergraduate Health Sciences Enrichment Program. This program provides an academic learning environment for entering college freshmen that are interested in a career as a healthcare professional. The program will challenge students with a rigorous curriculum in academic, social, and developmental support. This program seeks to identify students who demonstrate the following characteristics: Financial need; Academic performance or promise; Interest in pursuing a health-related career; Strength of character, evidence of leadership potential, and emotional maturity and stability; The potential to contribute to one s community later in life. Please provide your contact information below, in the case that the Office for Diversity staff has any pending questions or concerns. Recommender Name: Phone Number: Relationship to Applicant: To help in the selection of participants into the Undergraduate Health Sciences Enrichment Program, we ask that you please answer all of the following questions. Please limit your answers to the allotted space provided. ALL COMPLETED RECOMMENDATION FORMS MUST BE SUBMITTED IN A SEALED ENVELOPE TO THE STUDENT PRIOR TO THE APPLICATION DEADLINE OF MONDAY, MARCH 20, How long and in what capacity have you known this applicant?

10 Please describe the applicant s strengths? Please comment on the applicant s area(s) of development. What efforts has the applicant made to improve? How has the applicant contributed above and beyond her/his expected responsibilities? Please use the following space to include any additional comments. (Optional) Please rate the applicant on the following categories: Cannot Recommend Below Above Excellent Academic Performance Leadership Qualities Emotional Maturity Reliability Ability to interact with adults and peer Professionalism Resiliency (Ability to overcome barriers)