Albert Einstein College of Medicine of Yeshiva University Hispanic Center of Excellence (HCOE) Summer Undergraduate Mentorship Program 2010

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1 Applicant s Name: School address: Name of Recommendation Letter Writer: Writer s address: Letter of Recommendation Writer Telephone Number: Fax: Number: Application Please provide complete information below: Background Information: Student s Name: Last First Middle Initial Permanent Address: Street Current Mailing Address: City State Zip Code Street City State Zip Code School Personal I prefer you me at: school Personal School Telephone Number: Home Telephone Number: Cell Phone Number: Pager: I prefer you call me at: School Phone Cell Phone Home Phone Pager Male Female Place of Birth: Date of Birth:

2 Mother s Name: Occupation: Home Telephone Number: Father s Name: Occupation: Last First Middle Initial Ethnicity : Work Telephone Number: Last First Middle Initial Ethnicity: Home Telephone Number: Work Telephone Number: Demographics: Are you a US Citizen? Yes No If No (please provide visa type and nationality): Ethnicity: (check if applies): American Indian or Alaskan Native Asian Black or African American White (not of Hispanic Origin) Native Hawaiian or Pacific Islander Please specify (may check multiple choices): Cuban Dominican Mexican American Puerto Rican Other Hispanic Please specify Do you speak another language? Yes No Which one(s) Emergency Contact Information: Emergency Contact Person: Relationship to Student: Contact Number:

3 Education Information Name and Address of Current University/College: Name of Advisor: Address: Telephone Number: address: Have you ever attended another University/College? Yes No If yes when did you attend and where? If yes why did you decide to change schools? What is your Major? Minor? Overall GPA** Major GPA: ** The cumulative GPA must be apparent on transcript. If not, a letter from the Registrar s office must be included which indicates cumulative GPA. Transcript or letter should also indicate the current courses being taken. As of June 2010 how many years of college have you completed? Expected date of Graduation: Career Goal/area of interest/or medical specialty: Why? How many pre medical requirements have you completed? When are you expecting to take the MCAT exam? Have you taken a MCAT Review Course? Yes No If yes which one?

4 Where did you hear about this program? General Information What are your expectations from this program? What do you have to offer to this program? What volunteer work have you done in your community? Are you applying to other program? Yes No If yes which one? Scholarships, Prizes, Awards, Membership in Honorary and Professional Societies, Community Activities, Participation in other Health, Educational related programs: (i.e. HEOP, ASPIRA, STEP.) Since no housing is provided, if you do not live in the local area, if accepted where will you stay during the program?

5 PERSONAL STATEMENT Describe below what influenced your interest in the field of medicine and what you expect to accomplish during the mentorship experience. Please include information on your background, personal and professional goals and any prior community service or health related field experiences.

6 Financial Aid Information I receive a scholarship from my institution I receive State Financial Aid I receive Federal Student Aid I receive other Financial Aid Please explain: I receive loans If you checked off any item above, please go to your financial aid office at your institution and ask for a copy of your records or go online and print off the above information I do not receive financial aid Please do not send w-2 forms or any tax statements

7 Faculty Recommendation Form Applicant s Name: Last Name First Name Middle Initial Student applicants: Under the provision of the Family Educational Rights and Privacy Act of 1974, I do not waive the right to review the requested letter of recommendation. I waive the right to review the requested letter of recommendation. Name and Title of Recommender: (Please Print) Name of College/University: Address: Phone: Fax: Address: How long have you known the applicant? In what capacity? Please assess the applicant in the categories below based on your relationship and familiarity with the applicant compared to other students in the same class year Superior Among the Top 1% Outstanding Among the Top 5% Excellent Among the Top 10% Good Among the Top 33a% Average Among the Top 50% Below Average Below the Top 50% N/A No basis for Judgment Intellectual ability Maturity Leadership Work habits Academic preparation Integrity Initiative Ability to work well with others Ability to communicate Curiosity Analytical problem-solving skills Ability to adapt to new situations General motivation

8 Faculty Recommendation Form Please write a letter addressing the suitability of the applicant for this program:

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