The UMDNJ - School of Osteopathic Medicine 2011 Summer Pre-Medical Research & Education Program (PREP) Application

Transcription

1 The UMDNJ - School of Osteopathic Medicine 2011 Summer Pre-Medical Research & Education Program (PREP) Application Instructions: Please type or print clearly in black ink. Complete all sections of the application. Enclose or forward a transcript of all college coursework with the application and mail to the address below. Please do not fax applications. Letters of recommendation should be mailed by the person(s) completing the form to the same address. Please ensure that all materials reach our office no later than the application deadline of Monday, February 21, Personal Information 1. Name: Last First Middle 2. Current Mailing Address: Street City State Zip 3. Permanent Mailing Address: Street City State Zip Address: 4. Home Phone: ( ) Cell Phone: ( ) 5. Date of Birth: 6. Birthplace: City State Country 7. Please Check: MALE FEMALE U.S. Citizen: YES NO If No, please state country of citizenship: Permanent Resident: YES NO New Jersey Resident: YES No 8. Marital Status: Single Married Divorced Separated 9. Ethnic/Racial Self-Description: 10. Do you have a physical disability that requires specially designed instructional materials or programs, modified physical facilities, or related services to enable full participation in and access to the PREP program at UMDNJ-SOM? NO YES (please explain) 11. Father s/guardian s Name Phone ( ) 12. Address: Street City State Zip 13. Occupation 14. Mother s/guardian s Name Phone ( ) 15. Address: Street City State Zip 16. Occupation 17. Education Level: Father Mother 18. How many siblings do you have? Please list their ages: 19. Did any of them attend college: No Yes If Yes, please indicate the college(s) below: 20. Have you been convicted of a crime or found/pled guilty of a disorderly person s offense or misdemeanor?. Yes No (Exclude any minor motor vehicle offenses.) If yes, explain on a separate sheet and attach to application. Include any crimes, misdemeanors, or disorderly convictions.

2 Educational Information 21. What educational institution are you presently attending? 22. Are you a participant in your school s Educational Opportunity Fund (EOF) program? Check: YES NO 23. What year are you in school? GPA (cumulative) 24. What is your Major? Minor: 25. List courses you are currently enrolled in: 26. List any extracurricular activities you participate in (sports, hobbies, clubs, etc.): 27. Do you have an advisor? No Yes If Yes, please indicate the person s name and title: 28. How did you learn about Summer PREP? 29. Have you ever participated in a summer enrichment program? No Yes If Yes, indicate the name and location of the program: 30. List names, addresses and titles or occupations of two persons you have asked to complete the recommendation forms you received with your application: Name Title or Occupation Address Name Title or Occupation Address 31. Please write a short narrative on a separate sheet of paper in which you introduce yourself. Explain your interest in medicine, why you want to participate in Summer PREP, and why you would make an excellent participant. I certify that the above information is complete and true to the best of my knowledge. Your Signature Date Please return to: 2011 Summer PREP UMDNJ - School of Osteopathic Medicine Academic Center, Suite 210 One Medical Center Drive Stratford, NJ Phone: Fax:

3 The UMDNJ - School of Osteopathic Medicine 2011 Summer Pre-Medical Research & Education Program (PREP) Academic Center, Suite 210 One Medical Center Drive Stratford, NJ RECOMMENDATION FORM INSTRUCTIONS: This form must be completed by a pre-medical advisor, academic advisor, or science faculty member. Please have the individual completing this form return it directly to the above address. The applicant must sign this form below before giving it to the recommender for completion under the provision of the Family Education Rights and Privacy Act (Buckley Act). I waive any right of access that I might have to this recommendation form. I do not waive any right of access that I might have to this recommendation form. Full Name of Applicant: Last First Middle Evaluator: Please give your candid assessment of this applicant. Feel free to attach a letter in addition to the checklist provided. Specific descriptions of the individual's strengths and weaknesses are most valuable to the Selection Committee. Responses to the following questions can also assist the selection process: Does the applicant possess the academic potential for pursuit of medical studies? How would you rate the applicant s potential versus other students you have worked with? What personal characteristics of this applicant make her/him an outstanding candidate for Summer PREP? Thank you for your participation in our evaluation process!

4 Please use checkmarks in the table below to rate the applicant according to your observation or knowledge. Academic Performance Class Preparedness/Attendance Effort & Perseverance Self motivation Handles counseling or critique Communications Skills (verbal & written) Teamwork/Ability to work with others Aptitude for a career in clinical medicine or bio-medical research Judgment/Maturity Facility w/ computers, laboratory equipment, etc. Contributes to school/department community Leadership skills Intellectual curiosity/ability Analytical/ problem-solving skills Outstanding Excellent Satisfactory Fair Poor No knowledge or opportunity to observe In what capacity have you known this student? How long have you known this student? Printed name of person completing recommendation: Title: Institution: Signature: Date:

5 The UMDNJ - School of Osteopathic Medicine 2011 Summer Pre-Medical Research & Education Program (PREP) Academic Center, Suite 210 One Medical Center Drive Stratford, NJ RECOMMENDATION FORM INSTRUCTIONS: This form must be completed by a pre-medical advisor, academic advisor, or science faculty member. Please have the individual completing this form return it directly to the above address. The applicant must sign this form below before giving it to the recommender for completion under the provision of the Family Education Rights and Privacy Act (Buckley Act). I waive any right of access that I might have to this recommendation form. I do not waive any right of access that I might have to this recommendation form. Full Name of Applicant: Last First Middle Evaluator: Please give your candid assessment of this applicant. Feel free to attach a letter in addition to the checklist provided. Specific descriptions of the individual's strengths and weaknesses are most valuable to the Selection Committee. Responses to the following questions can also assist the selection process: Does the applicant possess the academic potential for pursuit of medical studies? How would you rate the applicant s potential versus other students you have worked with? What personal characteristics of this applicant make her/him an outstanding candidate for Summer PREP? Thank you for your participation in our evaluation process!

6 Please use checkmarks in the table below to rate the student according to your observation or knowledge. Academic Performance Attendance/Class Preparedness Effort & Perseverance Self-motivation Handles counseling or critique Communications Skills (verbal & written) Teamwork/Ability to work with others Aptitude for a career in clinical medicine or bio-medical research Judgment/ Maturity Facility with computers, laboratory equipment, etc. Contributes to school/department community Leadership skills Intellectual curiosity/ability Analytical/problem-solving skills Outstanding Excellent Satisfactory Fair Poor No knowledge or opportunity to observe In what capacity have you known the applicant? How long have you known the applicant? Printed name of person completing the recommendation: Title: Institution: Signature: Date: