INSTRUCTIONS FOR COMPLETING THE SCHOLARSHIP APPLICATION

2015 NATIONAL YOUTH LEADERSHIP FORUM ON MEDICINE-HOUSTON/GALVESTON SCHOLARSHIP APPLICATION The Texas A&M University System Health Science Center College of Medicine INSTRUCTIONS FOR COMPLETING THE SCHOLARSHIP APPLICATION The DEADLINE to submit your application is March 13, 2015. All supporting documents that must be mailed SHOULD be postmarked no later than March 13 th and received by March 20, 2015. The National Youth Leadership Forum on Medicine introduces outstanding high school students to the world of medicine. This ten-day program introduces students to professionals from some of the nation s top medical centers and faculty from renowned institutions of learning. Each year, the Texas A&M University System Health Science Center College of Medicine (TAMUS HSC College of Medicine) is one of the host for the National Youth Leadership Forum Medicine (NYLF/MED) at the Houston/Galveston site. We offer three need-based scholarships of $2,645.00 for students selected from Bryan and College Station high schools to attend the 2015 NYLF/MED Houston/Galveston Forum session II,. Eligibility An applicant must have the following qualifications: To be eligible for consideration, you must meet the following criteria: Must attend school at a Bryan or College Station high school Have a grade point average of B+ (87% or 3.30 on a 4.0 scale) or above and expected to graduate from high school in 2016 or 2017. Students who have not been nominated or do not meet the academic requirements may apply for a scholarship and will be considered on individual merit. Application A Complete Application File Consist of: NYLF Online Application (printed and mailed) Official High School Transcript ( mailed) Evaluation Form(s) printed and Letter(s) (mailed) Validation of High School Academic Record (printed and mailed) Supplement Data Request with photograph of yourself The application form is online and must be used to apply for the scholarship. It must be completed electronically, printed and mailed to our office. NYLFM Scholarship Appl--Instructions 15. wpd.doc 1

II. Supporting Documents: Must be mailed and should be postmarked no later than March 13 th and received by March 20 th. All supporting documents should have the same First, Middle name or Initial and Last name of the applicant. 1. The High School Validation of Academic Record form must be signed by your counselor or other school official. 2. Evaluation Form and Letters of Recommendation: a. A letter of evaluation/recommendation are required. The letter(s) can be from teachers, counselors, school administrators, and employers. Each letter must be submitted with a printed copy of the online Evaluation Form. b. Letters should focus on the following: Familiarity with you as a student and person (how known, how long, and how well known). Special strengths and weaknesses, any inconsistent aspects of academic record, ability to do independent work, extracurricular activities including employment, any unusual life circumstances or compelling factors, and overall suitability for the program. c. All letters of evaluation must be written on official school or business letterhead and mailed in official school or business envelope. Each letter must contain the evaluator s name, title, address, phone number and signature. Letters must be mailed by the evaluators directly to the TAMHSC COM Office of Admissions. A letter of evaluation is considered confidential unless you have arranged with the evaluator to retain the right of access to the letter of evaluation. Print online form and mail to the address below. 3. Official Transcript(s): Must be postmarked no later than March 13 th and received by March 20 th. Official transcript of academic work from high school and/or college (if applicable) must be sent directly to the College of Medicine Office of Admissions from your high school The transcripts must be certified with the official seal of the school and/or the signature of the school s Registrar. Be sure the transcripts are legible. NYLFM Scholarship Appl--Instructions 15. wpd.doc 2

4. Supplemental Data Request (Please print online form.) Information on Applicant s Race or Ethnic Group: Information on the applicant s race or ethnic group is requested in order to facilitate reporting of this information to the Association of American Medical Colleges (AAMC), the Texas Medical and Dental Schools Application Service (TMDSAS), and various governmental agencies that require the information. To assist the applicant s self-identification, the following guidelines are provided: American Indian/Alaskan Native A person having origins in any of the original peoples of North America and who maintains cultural identification through tribal affiliation or community recognition. Black/African American A person having origins in any of the Black racial groups of Africa (except those of Hispanic origin) Asian Pacific Islander A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent or Pacific Islands. (This includes, for example, China, Japan, Korea, Philippine Islands, India, Pakistan, American Samoa, and Vietnam.) Mexican American A person of Mexican culture or origin. Puerto Rican A person of Puerto Rican culture or origin. Other Hispanic A person of Cuban, Central, South American or other Spanish culture or origin. White/Caucasian A person having origins in any of the original peoples of Europe, North Africa, or the Middle East (except those of Hispanic origin). 5. Photograph: Submit one photograph of yourself. Approximate size of photograph should be 2¼" x 2½ ". Photocopy of photograph is not acceptable. Print and sign your name on the reverse side of the photograph. See the enclosed Supplemental Data Request Form for details. A photograph is requested to assist the admissions office and the admissions committee in identifying applicants during the review process. Note: The information submitted via the Supplemental Data Request will not be used in the evaluation process. Its sole purpose is to facilitate reporting to the appropriate agencies and to identify properly applicants during the processing of applications and formal interview process. Any questions concerning the status of a completed application should be directed to Ms. Wanda J. Watson, Director of Recruitment and Special Programs at wwatson@medicine.tamhsc.edu or call (979) 436-0237, Fax (979) 436-0097 Notification of receipt the scholarship will be March 30, 2015 NYLFM Scholarship Appl--Instructions 15. wpd.doc 3

TEXAS A&M HEALTH SCIENCE CENTER COLLEGE OF MEDICINE 2015 NATIONAL YOUTH LEADERSHIP FORUM ON MEDICINE HOUSTON/GALVESTON Date of Application: SS Number: - - PERSONAL INFORMATION The Scholarship Committee prefers that the Application Form be filled electronically, printed, and returned by mail. 1. Name (Last) (First) (Middle) Please check the box in item 2 or 4 to which correspondence concerning this application should be sent. 2. Permanent Address or Legal Residence (No. and street) (City) (County) (State) (Zip Code) (Area Code) (Phone Number) 3. Name of person to contact when you are not available. (Name) (Area Code) (Phone Number) E-mail: Fax: 4. Check if you wish to be considered a Disadvantaged applicant. It is necessary that you provide the family financial information requested in the Family Information section on page 6. Briefly explain in the box on page 6 the extenuating circumstances for your disadvantaged status. I certify that the information submitted in this application is complete and correct to the best of my knowledge and belief. I acknowledge that submission of any false information is grounds for rejection of my application, withdrawal of offer of acceptance or dismissal after acceptance. Signature of Parent or Guardian Date Signature of Student Date 1 NYLF/M FORM

VALIDATION OF HIGH SCHOOL ACADEMIC RECORD Provide grades either on a scale of 0-100 or 1.00-4.00. 5. Please provide the name and location of your high school. (Name of high school) (City) (County) (State) 6. Rank in Class Rank in Graduating Class Size of Graduating Class Mo/Year of Graduation 7. SAT and ACT Test Scores Most Recent Date Taken Verbal Math Total Score SAT Most Recent Date Taken English Math Reading Science Composite Score ACT 8. Grade Point Averages (GPA) and Credits: A minimum of an overall 3.3 or equivalent is required to be eligible. Please submit an official copy of your high school transcript. 9. Have your counselor or school official validate your academic record and/or complete this page, including test scores, by signing in the space below. Validation of Academic Record: (Signature of Counselor or School Official) (Position) (Date) 2

PERSONAL BIOGRAPHY 10. List major honors and distinctions, in order of importance to you, received both in and out of school. Award/Honor Description Level of Competition Date Rec d Ex: Regional Qualifier 1 of 3 chosen for regional team UIL 11. In priority order, list your most important extracurricular activities. (Estimate hours for spring of senior year and enclose w/circle.) Hrs per Wk / Wk s per Year Organization Leadership Position Description of Activities Level Fresh Soph Jr Sr Ex: Speech/Debate Club Tournament Chair Hosted speech tournament Regional 3 / 32 6 / 32 6 / 32 12. Describe the nature of your community/volunteer activities (Exs: Literacy Council, Food Bank, Meals on Wheels Volunteer, etc.). Activity Description/Role Dates Hours Ex: Habitat for Humanity Volunteer Helped build houses 5/99, 6-7/98 20 13. List significant health care, research experiences, academic enrichment, or jobs you have held or are holding. Activity Position/Responsibilities Dates Hours/Week Ex: Hospital Volunteer Emergency Room Assistant Assisted ER staff and patients 6/99-8/99 20 3

BIOGRAPHICAL DATA 1. Name (Full Legal) Last Name First Name Middle Name Suffix Preferred Name List all other LAST names which may appear on academic records 2. Citizenship If not U.S. citizen, Permanent Resident # 3. Gender Male Female Date of birth Place of birth Texas County FAMILY HISTORY AND DATA 1. Father s Information Name: Last Name First Name Middle Initial Place of birth Texas County Is father still living? Yes No Occupation Education If doctoral degree, indicate discipline Address Phone ( ) 2. Did someone other than your biological father play a significant male parental role in your life? Did you live with this person at least 3 years while attending high school? If yes, please provide: Name Relationship: Legal Guardian Adoptive Parent Stepparent Other Occupation Education If doctoral degree, indicate discipline 4

3. Mother s Information Name: Last Name First Name Middle Initial Maiden Name Place of birth Texas County Is mother still living? Yes No Occupation Education If doctoral degree, indicate discipline Address Phone ( ) 4. Did someone other than your biological mother play a significant female parental r ole in your life? Did you live with this person at least 3 years while attending high school? If yes, please provide: Name Relationship: Legal Guardian Adoptive Parent Stepparent Other Occupation Education If doctoral degree, indicate discipline 5. What do you consider your Home Town? City, State/Country 6. What was the primary language spoken at home? 7. Age of Siblings English Spanish African Dialect Asian Dialect Other Brothers Sisters 5

FAMILY INFORMATION 1. Are you a member of the first generation in your family to apply, to attend or graduate fr om: a. An undergraduate program? Yes No b. A graduate or professional program? Yes No *If no, how many in your family completed college? 1 2 3 4+ 2. Are you a parent/guardian of dependent children? Yes No If yes, how many were under your care? 0 1 2 3 4+ 3. Are you bilingual or multilingual? Yes No 4. What was your parents income, after taxes, for the year end? Less than $20,000 $20,000 - $30,000 $30,001 - $40,000 $40,001 - $50,000 $50,001 - $60,000 $60,001 - $70,000 $70,001 - $100,000 over $100,000 5. How many people are living in your parents household? 1 2 3 4 5 6 6. Estimated value of residential property: Less than $50,000 $50,000 - $75,000 $75,001 - $100,000 over $101,000 - $150,000 7. Did you or a member of your family ever live in subsidized housing? Yes No over $150,000 8. Did you or a member of your family ever r eceive benefits from the Federal Free and Reduced Meal program? Yes No 9. Did you have responsibilities in raising other children in your household while attending elementary and/or high school? Yes No 10. Were you required to contribute to the overall family income while attending elementar y and/or high school? Yes No PLEASE EXPLAIN THE EXTENUATING CIRCUMSTANCES FOR DISADVANTAGED STATUS 6

PERSONAL STATEMENT LETTERS OF RECOMMENDATION Two individual letters of recommendation are required from teachers. Additional letters may be included fr om counselors/administrators. 1. (Name) (Title/Position) (Department/Organization) 2. (Name) (Title/Position) (Department/Organization) I understand that the College of Medicine s Office of Admissions does not regard applications complete until all supporting documents have been submitted appropriately. These include official transcripts, letters of recommendation, and official test scores. I further understand that such documents must be sent dir ectly to the TAMHSC College of Medicine s Office of Admissions for processing. I certify that the information in this application and all attachments is complete and accurate to the best of my knowledge and belief. I understand that submission of any false information is gr ounds for rejection of amy application, withdrawal of any of fer of acceptance, or dismissal after enrollment and that the information is subject to verification. Signature of Applicant (Your application will not be processed without your signature.) Date 7

TEXAS A&M HEALTH SCIENCE CENTER COLLEGE OF MEDICINE NATIONAL YOUTH LEADERSHIP FORUM - MEDICINE SUPPLEMENTAL DATA REQUEST Name: SS Number: - - Last First M. I. 1. Information on the applicant's race or ethnic group is requested in order to facilitate reporting of the information to the Association of American Medical Colleges (AAMC), the Texas Medical and Dental Schools Application Service (TMDSAS), and various government agencies which require the information. Please indicate your race or ethnic group. (See Supplemental Data section of General Instructions.) SELECT ONE: American Indian/Alaskan Native Black/African American Asian/Pacific Islander Mexican American Puerto Rican (Mainland) Other Hispanic White/Caucasian Other (specify) Unreported NOTE: RESIDENT ALIEN: A Non-U.S. Citizen who has been lawfully admitted for permanent residence is to be reported in the appropriate racial/ethnic categories along with United States citizens. 2. A photograph is requested to assist the Scholarship Committee in identifying applicants being considered for the acceptance of the scholarship. Please submit a copy of your high school ID photo. Do Not attach the photograph here. On the back of the photo, print your name and sign it using a blue or black ink pen. Enclose the copy with this form but DO NOT paste or tape it to the form. 2 1 4ʺ 2 1 2ʺ Signature Date 8