APPLICANTION FOR THE HCOE ONLINE MCAT GUIDED STUDY PROGRAM April 15, 2015 July 8, 2015

Transcription

1 APPLICANTION FOR THE HCOE ONLINE MCAT GUIDED STUDY PROGRAM April 15, 2015 July 8, 2015 All notifications will be by . Students must fax or application to: Berengaria Navarre, M.S. E. T Pre-med Advisor: Contact Phone: Contact I. PERSONAL INFORMATION Last Name: First Name: MI: Address: City: State: Zip Code: County: Date of Birth: Number of Years at this Address: Place of Birth: Male: Female: Personal School Applicant s Phone #: II. EDUCATIONAL INFORMATION (A transcript is required. An unofficial transcript is acceptable but we prefer that it is sent by the pre-med advisor.) High School Overall GPA: High School Science GPA: Composite SAT Score: Date taken: Math: Writing: Critical Reading: Composite ACT Score: Date taken: English: Reading: Math: Science: 1

2 Latest MCAT Score: MCAT Score: MCAT Score: Date taken: Date taken: Date taken: Total college credit hours by end of current year: _ Current Cumulative GPA: Major: Current Science GPA: Minor: Check academic school year : _Freshman Sophomore Junior _Senior Anticipated graduation: Month Year School Check if applicable: Former Academic and Enrichment Program student. School: UTB _UTPA UTEP Former MCDP Level 1 student Please check the school that you attend: Laredo Community College University of Texas Pan-Am at Edinburg Lamar University University of Texas at Brownsville Texas A&M University at Kingsville Texas A&M University at Corpus Christi University of Texas at El Paso Other (school name) List graduate school(s) you anticipate applying to: III. FAMILY HISTORY Father s Name: Highest Education Level: Father Alive: _Yes No Occupation: Employer and Phone #: 2

3 Personal Phone #: Mother s Name: Highest Education Level: Mother Alive: Yes No Occupation: Employer and Phone #: Personal Phone #: Number of siblings attending college: Number of siblings: How many generations of your family have lived in the State of Texas: _? Is English your first language: Yes No? If no, what is your first language: your home _? What is the predominant language spoken in _? List all languages in which you are fluent (other than English): IV. TECH HISTORY laptop smartphone: If yes, type: mp3 player video camera Ipad/tablet How Social are You? _Facebook Twitter Podcasting You tube _Ning Wordle Prezi Quizlet _Other: name How Tech are You? (use only space provided): V. FINANCIAL INFORMATION Do you currently support any minor dependents? Yes _No If yes, list ages: What was your parents after-taxes income for the 2010 tax year: (check one) 0-$10K $10,001 - $20,000 _$20,001 - $30,000 $30,001 - $40,000 3

4 $40,001 - $50,000 _$50,001 - $60,000 $60,001 - $70,000 Over $70,001 If your family owned a home, please estimate the value of the home in which you were raised (check one): _< than $50,000 $50,001 - $60,000 _$60,001 - $70,000 $70,001 - $80,000 _$80,001 - $90,000 Over $90,000 Please check the type of community/neighborhood in which you grew up: Definitions: City: population > 100,000; Inner City: current part of the city, densely populated and low income; Suburban: residential area adjacent to a city; Town: population 50, ,000; Rural: county and/or farming area City Inner City _Suburban Town Rural List all full- and part-time employment experiences including summers that you have held for the past two years. Use a separate sheet if necessary Company/Organization Position Dates Hours per week VI. BIOGRAPHICAL INFORMATION a. List any academic honors, awards, and other recognitions received while in high school and to the present Honor/Award Organization Date 4

5 b. List any leadership roles or positions of responsibility held while in high school and to the present Position Role Date c. List any health-care related community service, volunteer, or employment experiences you have participated in while in high school and to the present Position Role Date d. List any non health-care related community service or volunteer activities you have participated in while in high school and to the present Position Role Date 5

6 e. List extracurricular activities you have participated in while in high school and to the present Activity Role Date f. Please provide a detailed explanation of how you will manage your time in order to maintain or improve your GPA and spend at least 10 to 12 hours a week studying for the Medical College Admission Test. NO ATTACHMENTS ACCEPTED - USE SPACE ONLY PROVIDED HERE 6

7 VII. PERSONAL COMMITMENT An essential component of this study program is your commitment to study 10 hours a week or more for the Medical College Admission Test. Students who do not comply with their commitment may be asked to leave the program. You agree to: Check into the online classroom four days a week, study 10 or more hours a week, and maintain contact with HCOE staff. Participate in live sessions unless you notify HCOE staff ahead of time. Provide an and phone that you regularly check and respond to contacts from HCOE staff within 24 hours. Obtain required books and register with the AAMC website. Notify Berengaria Navarre as soon as possible, if circumstances prevent you from completing your assigned activities. I certify the information provided in the above application is complete and correct to the best of my knowledge. Please sign and date after completing document. (e)signature: Date: Data Request Form 1. Please indicate your race or ethnic group as follows: American Indian/Alaskan Native Black/African American Asian/Pacific Islander Mexican American Hispanic White/Caucasian Other (specify) Unreported Puerto Rican (Mainland) 2. Photographs are requested to assist the committee members in identifying and remembering applicants being considered for acceptance in the Medical Careers Diversity Program. 7

8 Please submit one photograph. It should be a recent photo and approximately 2 X 3 in size. 2 X 3 Photo here If mailing a hard copy application, please print name on back of photograph Must ANSWER Are you a Texas resident? Yes No How many years have you lived in Texas? Are you a US citizen? Yes No If not, what is your citizenship? Provide the Visa type or resident status: Date issued: Are you currently under charge or have you ever been convicted of a felony or misdemeanor, other than minor traffic violations, or have you ever received a felony or misdemeanor deferred adjudication? Yes No. An applicant need not disclose information about a juvenile or criminal record that has been sealed or expunged. Failure to disclose information may result in the applicant being denied acceptance into the program. If yes, explain fully including dates. Please use space provided below. Do not include routine traffic violations DWI, DUI and DWL must be listed 8

9 Hispanic Center of Excellence Staff Director Norma A. Perez, M.D., Dr.P.H. (409) Manager Berengaria Navarre, M.S. (409) Submission Process VIA , FAX, OR SNAIL MAIL Application forms, Letters of Reference, and Transcripts must be sent to Berengaria Navarre M.S. Mailing Address: University of Texas Medical Branch, 301 University Blvd., Galveston, Texas , Ashbel Smith Building, Rm , Office of Student Affairs and Admissions Fax Number: (409) Please visit our website for updates: 9