APPLICATION FORM POST-BACCALAUREATE HEALTH PROFESSIONS

Transcription

1 Post-Baccalaureate Health Professions 1505 University Ave., 178 UCB Boulder, CO ce.colorado.edu/advising P: (303) F: (303) APPLICATION FORM POST-BACCALAUREATE HEALTH PROFESSIONS PART I. BIOGRAPHICAL INFORMATION Full Legal Name (Last) (First) (Middle) Sex (M/F) Former or maiden name Preferred First Name Preferred pronoun (If applicable) Date of Birth Social Security Number CU Student ID# (Required for TRA Tax Credits & COF Verifications) (If applicable) Contact Information: Phone # address Mailing Address City State Zip CITIZENSHIP ETHNICITY and RACE SELECTIVE SERVICE CERTIFICATION U.S. Citizen Non-U.S. Citizen - permanent status Alien registration # RESIDENCY Colorado Other state (state abbr.: ) Are you of Hispanic, Chicano, Mexican, Latino, Cuban, Puerto Rican, South or Central American or Spanish origin? Yes No Check one or more: American Indian or Alaskan Native Black or African-American Asian Native Hawaiian or other Pacific Islander White If American Indian or Alaskan Native, are you an enrolled member of a federal or state recognized tribe with tribal affiliation documentation? Yes No Please indicate tribe name: I certify that I am registered with the Selective Service. I am not required to register with the Selective Service because: I am a female. I am in the U.S. Armed Forces on active duty. I have not yet reached my 18 th birthday. I am age 26, or older, by the first day of class. I am a non-immigrant alien lawfully admitted in the U.S. 1

2 Complete this section if you have not attended any University of Colorado campus within the last 12 months, and are claiming in-state tuition classification. If you do not provide this information you will be classified as a nonresident and may have to pay out-of-state tuition. (NOTE: Failure to answer each question may result in your being classified as a nonresident.) Dates of continuous physical presence in Colorado (mo./day/yr.)... Dates of employment in Colorado.. List exact years personal, Colorado resident income taxes have been filed. Dates of extended absences (more than 2 months) from Colo. over the past two years. Dates of active military service, if applicable.. If military, dates stationed in Colorado. Driver s License # Dates of Colorado driver s license.. License Plate # List exact years of Colorado motor vehicle registration... Dates of Colorado voter registration. Dates of ownership of a home (as a primary family residence) in Colorado... YOU CRIMINAL HISTORY Do you have a pending criminal charge OR have you ever been adjudicated guilty or convicted of a misdemeanor, felony, or other crime? Note that you are not required to answer "yes" to this question, or provide an explanation, if the criminal adjudication or conviction has been expunged, sealed, annulled, pardoned, destroyed, erased, impounded, or otherwise ordered by a court to be kept confidential. (Misdemeanor traffic offenses are exempt.) If yes, download and submit the Criminal History Supplement form. No Yes NONACADEMIC SUSPENSION Have you ever been placed on probation, suspended, expelled, or been subject to official disciplinary action from any high school or postsecondary institution for any academic misconduct or behavioral misconduct? If yes, download and submit the Nonacademic Suspension Information Form. No Yes Failure to answer either the Criminal History or the Nonacademic Suspension questions will stop the processing of your application. If you answer yes to either question, you must include a written explanation on the supplemental form. EDUCATIONAL GOAL (Ex: Medical school, dental school, veterinary school, physician s assistant program, anesthesiologist s assistant program, etc.) Indicate if interested in a dual degree program. DISADVANTAGED STATUS Do you believe you qualify for disadvantaged status? If so, indicate the criteria below that pertain to you. (Check all that apply.) First-generation college student (at a four-year institution) Growing up in a medically underserved community Family participation in state and federal assistance programs Attending college on a Pell Grant LANGUAGE Languages Spoken with level of proficiency. Please indicate which language you speak at home. (You may add to this list if you speak more than one or two languages.)

3 PART II. PERSONAL STATEMENT Maximum of 5,500 characters, including spaces. Refer to instructions document for guidelines. 3

4 PART III. ACADEMIC INFORMATION EDUCATIONAL HISTORY Do you have a college degree? Yes No Highest degree received Graduation Date List all colleges/universities attended and dates of attendance. Name of Institution Dates of Attendance AP/IB Credit: If you were granted college credit for AP/IB course work in any of the following subjects, list that credit here. (Biology, Chemistry, Physics, Math, English Literature, Writing/Composition, Psychology, Sociology) Course Subject Undergraduate institution that granted credit for this course List any BCPM courses you have already completed (Refer to instructions document for guidelines. You may copy the format to an additional document if more rows are needed.) Name of Course Institution Where You Took the Course Credit Hours Grade Included Lab? (Y/N) List any current/planned courses from present until June 2018 (You may copy the format to an additional document if more rows are needed. Name of Course Course Prefix and Number Institution Where You Will Complete the Course Credit Hours Included Lab? (Y/N) 4

5 PART IV. EXPERIENCES For each entry, use the template below. (You may copy this format to another document as needed.) Within each category, list your experiences in reverse chronological order (most recent first). There is no limit to the number of entries you may list within each category. Refer to the Instructions document while completing this section. CLINICAL SHADOWING OR SCRIBING DIRECT PATIENT INTERACTION 5

6 RESEARCH ACTIVITIES DIRECT SERVICE TO OTHERS (EITHER PAID OR VOLUNTEER) HONORS, AWARDS, SCHOLARSHIPS, ACADEMIC ENRICHMENT PROGRAMS 6

7 OTHER PAID EMPLOYMENT LEISURE ACTIVITIES 7

8 FOR VETERINARY APPLICANTS ONLY ANIMAL HANDLING EXPERIENCE (NOT RESEARCH OR CLINICAL) PART V. RECOMMENDATIONS Please list the two individuals that will submit recommendations for you. Please do not include family members. The recommendations should be from individuals with whom you studied or worked with in an academic or professional setting. One of each, or two academic letters are preferred. Letters should be ed directly from the recommender to or mailed to: Post-Baccalaureate Health Professions 1505 University Ave., 178 UCB Boulder, CO Name Association Name Association SIGNATURE I hereby certify that, to the best of my knowledge, the information furnished on this application is true and complete. I understand that if found to be otherwise, it is sufficient cause for rejection or dismissal. I agree to observe all campus policies and regulations including the Honor Code. Signature: Date: 8