University of Michigan School of Dentistry PROFILE FOR SUCCESS (PFS) PROGRAM Program Dates: May 20-June 28
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1 University of Michigan School of Dentistry PROFILE FOR SUCCESS (PFS) PROGRAM 2013 Program Dates: May 20-June 28 Instructions: Application should be typed; handwritten applications will NOT be accepted. Complete all sections of application. Return the application to the address below. Applications must be postmarked by February 4, Pre-Dental Program Part I. Identifying Information Last Name: First: Middle: Date of Birth: / / SSN: - - Female Male Current Mailing Address: (I will be at this current address until / / ) Street: City: State: Zip Code: Current Phone: ( ) - Permanent Mailing Address (where you can be reached after July 1, 2013): Street City State Zip Code Permanent Phone ( ) - Citizenship: Applicants must be a US citizen or permanent resident to participate in the program (check one) US Citizen Permanent resident Profile for Success Program University of Michigan School of Dentistry 1011 N. University Ave. Rm G226 Ann Arbor, MI Phone: (734)
2 Parent Information Father Name: Occupation: Martial Status: Married Single Widowed Divorced Separated Education: Less Than/Partial High School High School Graduate Some College Associates Degree BA/BS Degree Graduate School Professional School (specify) Mother Name: Occupation: Martial Status: Married Single Widowed Divorced Separated Education: Less Than/Partial High School High School Graduate Some College Associates Degree BA/BS Degree Graduate School Professional School (specify) Program Qualifications Please provide the following information. Using the guidelines below to determine eligibility, check the appropriate boxes that apply to you. To explain your eligibility, please submit a corresponding typed statement for each category checked titled PFS Qualification Essay. Only one category is necessary to qualify. Include any documents that can support your essay: 1. Economically disadvantaged: If you checked this box, explain any economic hardships experienced by you and/or your immediate family. A student who comes from a low income family with an annual income below the thresholds published in the Federal Register by the Secretary, DHHS, for use in all health professions programs (see page 8 for income guidelines). 2. Educationally disadvantaged: If you checked this box, describe your high school and/or undergraduate college experience that would qualify you as disadvantaged. 2
3 A student who comes from a community college or a less competitive four-year institution, as defined by Barron s Profiles of American Colleges. Standardized test scores (ACT/SAT) at student s school are markedly below other institutions, or student performance on standardized tests (ACT/SAT) is below national norms AND student has an overall grade point average below 3.0 or a science grade point average below A student who attended secondary school in a financially designated poor district. Parents or other adults in the household are not high school graduates. A student who lacked the opportunity to gain academic enrichment from other sources. 3. Socially disadvantaged: If you checked this box, explain any experiences that would qualify you as socially disadvantaged. A student who comes from an environment that has inhibited (but not prevented) him or her from obtaining the knowledge, skills and abilities required to enroll in, and successfully complete an undergraduate course of study that could lead to a career in the health sciences. This includes, but is not limited to: First generation college students, students limited by their community setting (rural, inner city or reservation), students with a certified learning and/or physical disability, students from a single-parent household, or students from a foster-care setting for the majority of their K-12 experience. 4. Demonstrated commitment to improving the health of the underserved and disadvantaged populations: If you checked this box, explain your commitment to improving the health of the underserved and disadvantaged populations. How have you demonstrated this commitment (include examples of community service and/or outreach experiences)? Personal life experiences with underserved communities and/or experiences concerning disadvantaged health issues that have motivated you to pursue training in dentistry/medicine. Significant volunteer or other work for a clinic or agency serving the underserved or disadvantaged populations (local, national or international). Other experiences (e.g. specific courses taken) which have prompted you to focus on improving the health of underserved and disadvantaged populations. I certify the information provided in this application is true to the best of my knowledge. If needed, I will supply information to document my status as a student from a disadvantaged background, or my demonstrated commitment to improving the health of underserved and disadvantaged populations. Signature: Date: 3
4 Part II. Education History 1. Name of current College/University: City State Zip Code College Standing: Junior Senior Graduate Major/Minor: Total credit hours completed Cumulative grade point average (GPA) List in chronological order all colleges or universities you have attended (Use additional sheets if necessary): 1. College/University City, State Dates Attended Degree Granted e.g.- B.S., B.A., M.S. Total Credit Hours Completed Cumulative GPA The following courses must be completed or in progress to participate in the pre-dental PFS program (please note that students must have a cumulative and science GPA of 2.5 or higher to participate in the program): 2 Semesters of Biology with Labs 2 Semesters of Inorganic Chemistry with Labs 2 Semesters of Organic Chemistry with Labs 1 Semester of College level Math 1 Semester of English Composition 1 Semester of Physics (recommended, but not required) Please list all college level courses on the next page. 4
5 Please list all Biology, Chemistry, Physics, Math, English, Sociology and Psychology course(s) you have completed, or are currently in progress. Include the grade received, and the semester/term you took the course. Please be advised that all program pre-requisites must be fulfilled prior to the program in order to qualify for admission into PFS. COURSE SEMESTER COMPLETED GRADE RECEIVED 5
6 Have you previously taken the Dental Admissions Test (DAT)? This question needs to be answered by ALL applicants. No, anticipated test date: / / Yes, date taken (please list all previous test dates): / / (List DAT scores for all test dates and attach a copy of your score reports) Academic Average Science Average PAT Bio General Chemistry Organic Chemistry Reading Comprehension Quantitative Reasoning Have you taken a DAT review course? Yes, if yes, where? How will taking another course help? (Use a separate sheet to respond to this question) No Have you previously taken the Medical College Admissions Test (MCAT)? This question needs to be answered by ALL applicants. No, anticipated test date: / / Yes, date taken (please list all previous test dates): / / (List all MCAT scores for all test dates and attach a copy of your score reports) Physical Sciences Total Raw Score Verbal Reasoning Score Biological Sciences Score Writing Sample Total Raw Score Have you taken an MCAT review course? Yes, if yes, where? How will taking another course help? (Use a separate sheet to respond to this question) No Have you previously applied to Dental School? Yes No If yes, when? Have you previously applied to, or are you currently applying to a health professional School other than Dental School? Yes No If yes, when and what type of program? 6
7 Extra-Curricular Activities: List any extracurricular activities (sports, hobbies, clubs, etc.). You may use a separate sheet of paper if necessary. Have you ever participated in a summer academic enrichment program focused on the sciences, or summer research program? No Yes, please list the name of the program, the location and dates attended: How did you hear about our program? Friend Advisor Website Other: 7
8 References: Three (3) letters of recommendation should be sealed and signed across the envelope closing by each person writing the recommendation. Note: Two letters should be written by two different science instructors. One letter may be written by an advisor, counselor, employer or other person of your choice. List names and titles of the people you have asked to complete the 3 recommendation forms you received with your application. YOUR REFERENCES SHOULD INCLUDE AT LEAST TWO DIFFERENT SCIENCE INSTRUCTORS. Name Title Institution address Name Title Institution address Name Title Institution address Please provide a typed essay titled PFS Personal Statement in which you introduce yourself by addressing the following questions in 3-5 pages: What exposure have you had to the field of dentistry, and how has this influenced you? What are your goals as a health professional? What unique skills, qualities or life experiences would you bring to a health profession? Why do you want to participate in this program and how will you benefit from this program? State 3 goals you would like to accomplish during this program. What will you contribute to the overall experience of this program? Attach your personal statement to your application, and include page numbers and your name on each page of your statement. Please save an electronic version of your answers to be used if you are accepted into the program. I certify that the above information is true, complete and accurate to the best of my knowledge. I understand that excluding relevant information or providing misrepresentations, false, or misleading information in my application and/or supporting documents may result in the suspension of my application, and/or other actions including dismissal from the PFS program if admitted. Furthermore, I understand that falsifying or providing incorrect information may jeopardize my participation in programs at the University of Michigan. Student Signature Date 8
9 Application packets must be postmarked by February 4, Application checklist: Please staple your application. PFS Qualification Essay: essay explaining how you qualify for PFS. Any documents that can support this statement. A list of the Biology, Chemistry, Physics, Math, English, Sociology and Psychology course(s) you have completed and/or in which you are currently enrolled. PFS Personal Statement: 3-5 page statement addressing the questions stated on page 8. A current resume 2. Do not forget that the following pieces of information are required for your application to be complete: Three letters of recommendation. Two letters should be from science instructors/ professors and the third can be from an individual of your choice. Official college transcripts from each institution you have attended. 3. Please note: Each letter of recommendation needs to be in a sealed envelope that is signed across the seal. All transcripts need to be official. Please send application packet, transcripts, and letters of recommendation to: Profile for Success Program The University of Michigan School of Dentistry 1011 N. University Ave Rm G226 Ann Arbor, MI
10 Income Guidelines Section 673(2) of the Omnibus Budget Reconciliation Act (OBRA) of 1981 (42U.S.C. 9902(2)) requires the Secretary of Health and Human Services (HHS) to update the poverty guidelines at least annually, adjusting them on the basis of the Consumer Price Index for All Urban Consumers (CPI-U). The poverty guidelines are used as an eligibility criterion by the Community Services Block Grant program and a number of other Federal programs Poverty Guidelines Persons in family/household Poverty guideline $11, $15, $19, $23, $27, $30, $34, $38, Source: 10
11 CONFIDENTIAL Applicant Recommendation Form The University of Michigan School of Dentistry and Medical School hosts a seven-week summer program, Profile for Success, which is designed to expose participants to health careers in dentistry and medicine for the purpose of developing competitive applicants for dental and medical schools. Your candid and thoughtful evaluation of the applicant is greatly appreciated. Please return this completed form and attached letter of recommendation to the address below. Letters should be postmarked no later than February 4, Please check the appropriate box for each category or indicate N/A for those categories where you have no basis to judge. In your letter, please describe the student s qualities, characteristics and if known, potential as a health care professional. Also include any known academic weaknesses (test-taking, study skills, writing, etc.) to assist us in working with the student during the program. Student Name: Relationship to applicant: Characteristics Excellent Very Good Fair Poor No Basis to Judge Appearance & Presentation Personality Maturity & Judgment Dependability & Reliability Perseverance Character & Integrity Initiative Self Esteem Leadership Potential as a Health Professional Name College/Department Position/Title Signature Date PLEASE SEND THIS FORM TO: Profile for Success University of Michigan School of Dentistry 1011 N. University Ave. Rm G226 Ann Arbor, MI
12 CONFIDENTIAL Applicant Recommendation Form The University of Michigan School of Dentistry and Medical School hosts a seven-week summer program, Profile for Success, which is designed to expose participants to health careers in dentistry and medicine for the purpose of developing competitive applicants for dental and medical schools. Your candid and thoughtful evaluation of the applicant is greatly appreciated. Please return this completed form and attached letter of recommendation to the address below. Letters should be postmarked no later than February 4, Please check the appropriate box for each category or indicate N/A for those categories where you have no basis to judge. In your letter, please describe the student s qualities, characteristics and if known, potential as a health care professional. Also include any known academic weaknesses (test-taking, study skills, writing, etc.) to assist us in working with the student during the program. Student Name: Relationship to applicant: Characteristics Excellent Very Good Fair Poor No Basis to Judge Appearance & Presentation Personality Maturity & Judgment Dependability & Reliability Perseverance Character & Integrity Initiative Self Esteem Leadership Potential as a Health Professional Name College/Department Position/Title Signature Date PLEASE SEND THIS FORM TO: Profile for Success University of Michigan School of Dentistry 1011 N. University Ave. Rm G226 Ann Arbor, MI
13 CONFIDENTIAL Applicant Recommendation Form The University of Michigan School of Dentistry and Medical School hosts a seven-week summer program, Profile for Success, which is designed to expose participants to health careers in dentistry and medicine for the purpose of developing competitive applicants for dental and medical schools. Your candid and thoughtful evaluation of the applicant is greatly appreciated. Please return this completed form and attached letter of recommendation to the address below. Letters should be postmarked no later than February 4, Please check the appropriate box for each category or indicate N/A for those categories where you have no basis to judge. In your letter, please describe the student s qualities, characteristics and if known, potential as a health care professional. Also include any known academic weaknesses (test-taking, study skills, writing, etc.) to assist us in working with the student during the program. Student Name: Relationship to applicant: Characteristics Excellent Very Good Fair Poor No Basis to Judge Appearance & Presentation Personality Maturity & Judgment Dependability & Reliability Perseverance Character & Integrity Initiative Self Esteem Leadership Potential as a Health Professional Name College/Department Position/Title Signature Date PLEASE SEND THIS FORM TO: Profile for Success PLEASE SEND THIS FORM TO: Profile for Success University of Michigan School of Dentistry Attn: 1011 N. Helen University Fotinos, Ave. Rm Program G226 Coordinator University Ann Arbor, MI of Michigan School of Dentistry, Suite N. University Ann Arbor, MI
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