UNDERGRADUATE HEALTH SCIENCES ENRICHMENT PROGRAM PROGRAM DATES: JUNE 12, 2015 JULY 24, 2015

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1 UNDERGRADUATE HEALTH SCIENCES ENRICHMENT PROGRAM PROGRAM DATES: JUNE 12, 2015 JULY 24, 2015 APPLICATION DEADLINE: 5:00PM, FRIDAY, APRIL 10, 2015 The Undergraduate Health Science Enrichment Program (UHSEP) is a six-week academically rigorous residential program at the University of New Mexico (UNM) Health Sciences Center (HSC) that provides an academic learning environment for entering college freshmen who are interested in a career as a healthcare professional. UHSEP was designed to meet the needs of New Mexico by educating youth to become competitive applicants to enter health professional schools. The program will challenge students with a rigorous curriculum in academic, social, and developmental support. UHSEP students are expected to approach the experience with a commitment toward scholarship and career exploration. Interested applicants must be New Mexico residents, as defined by the UNM School of Medicine, Preferably, underrepresented in medicine and come from economically and/or educationally disadvantaged backgrounds. Applicants should demonstrate a commitment to increasing health equity. Applicants accepted in to our HEALTH NM pipeline programs must have a Social Security Number (SSN) or Individual Tax Identification Number (ITIN). Questions regarding citizenship, residency and/or application details can be directed to or by calling or toll free Student Eligibility Minimum GPA of 2.75 on a 4.0 scale Current seniors/recent high school graduate/ged Recipients entering post-secondary institution (college, university, etc.) Participation Dates The program will begin on Friday June 12, 2015 and end on Friday July 24, Student participation is expected throughout the duration of the program; participants will be required to stay on campus unless otherwise indicated (free weekend information will be given at a later date), during the specified time period. All accepted student participants are expected to attend the program orientation on Friday, June 12 th. They are encouraged to stay and participate in the UNM Science, Technology, Engineering, Arts, Math and Health (STEAM-H) Career Exploration Extravaganza on June 12 14, This event will be a two-day event to introduce students to many engaging and hands-on science and healthcare experiences. The Office for Diversity may be able to provide transportation to the UNM Health Science Center on Friday June 12, This event is FREE and will provide lodging and food for participants. Further information and details will be provided at a later date to those students who are accepted into the program. Failure to include any of the supporting documents, not following directions completely, or leaving blank sections on this application form will result in an automatic disqualification. Additionally, failure to meet the April 10, 2015 deadline will result in automatic disqualification. To apply, please complete the attached application. If accepted into the program, the Office for Diversity will send all participants an acceptance packet that must be completely filled out and returned to our office no later than Friday, May 15, Accepted participants must need to submit proof of their post-secondary college acceptance and immunization records with current TB test. ALL COMPLETED APPLICATIONS MUST BE SUBMITTED VIA METHODS LISTED BELOW BY 5:00PM ON APRIL 10, 2015 OR POSTMARKED ON OR BEFORE APRIL 10, FAXED APPLICATIONS WILL NOT BE ACCEPTED. Mail to: UNM HSC Office for Diversity MSCO University of New Mexico Albuquerque, NM SUBMIT COMPLETE APPLICATION BY APRIL 10, 2015: Apply Online at: Deliver in person to: UNM Health Science Center, UNM North Campus Office for Diversity Health Sciences and Services Building, Suite 102 Building #266, Campus Map UHSEP Application Revised January 16, 2015 HCOP Funded by HRSA-D18HP24088

2 UNDERGRADUATE HEALTH SCIENCES ENRICHMENT PROGRAM PROGRAM DATES: JUNE 12, 2015 JULY 24, 2015* APPLICATION CHECKLIST APPLICANT NAME: Complete application packets must include: Complete Student Application High School Transcript(s): An unofficial copy of your high school transcript Resume ACT or Pre-ACT Scores (if applicable): include a copy of your exam score(s), if not listed on your transcript(s) Personal Statement: (The personal statement must be typed, double-spaced, 12-point font, Times New Roman, 1 margins, and no more than 2 pages.) Please state your purpose in applying to this program. In this personal statement we are seeking to capture not only a snapshot of where you are currently as a student but also where you have been and where you see yourself in the future as a health professional. Relevant factors include but are not limited to the following: Achievements you have accomplished dispite of educational, social, and economic challenges. What in your personal, work, or academic background has motivated your interest in a health career? What are your educational goals and how will they impact you, your family, and your community? What kind of educational experiences and skillset do you expect to gain this summer that will best assist you in reaching your career goals and dreams? Two Completed Recommendation Forms One form should be completed by someone who can evaluate your character and academic performance, such as a professor, teacher, counselor, principal, mentor, employer, or volunteer supervisor. The second form can be from someone of your choosing. Forms must be in a sealed envelope with the writer s signature across the seal on the back of the envelope. * All accepted student participants are expected to attend the program orientation on Friday, June 12 th. They are encouraged to stay and participate in the UNM Science, Technology, Engineering, Arts, Math and Health (STEAM-H) Career Exploration Extravaganza on June 12 14, This event will be a two-day event to introduce students to many engaging and hands-on science and healthcare experiences. The Office for Diversity may be able to provide transportation to the UNM Health Science Center on Friday June 12, This event is FREE and will provide lodging and food for participants. Further information and details will be provided at a later date to those students who are accepted into the program. Office Use Only Date Submitted: Staff Initials: UHSEP Application Revised January 16, 2015 HCOP Funded by HRSA-D18HP24088

3 PERSONAL INFORMATION UNDERGRADUATE HEALTH SCIENCES ENRICHMENT PROGRAM STUDENT APPLICATION Please make sure that the information given in this section is accurate and matches with any federal or state issued document (ex. Social security card, ITIN card). 1. Name: Last First Middle 2. Address: Street Address or P.O. Box Number City or Town County State Zip Code 3. Phone: Address: 4. UNM Banner or Student ID: 5. Gender: Female Male 6. U.S. Citizen: Yes No If no, can you provide a SSN or ITIN: Yes No 7. New Mexico Resident: Yes No If no, state of residency: 8. Date of Birth: 9. Place of Birth: 10. Do you consider yourself to be Hispanic/Latino(a)? Yes No In describing yourself, please select one or more of the following racial categories: American Indian or Alaskan Native (Specify affiliation): 11. What was your first language? Asian Black or African American Native Hawaiian/Pacific Islander White Other (Please specify): What is the primary language spoken at home? EDUCATIONAL BACKGROUND 12. List in order all the schools you are attending and/or have attended beginning with high school: High School: College: 13. Current Grade Level: School Name City and State Dates of Attendance Cumul. GPA 14. Have you taken the ACT? Yes No What was your composite score? Test Date: 15. Have you taken the SAT? Yes No What was your composite score? Test Date: 16. Did you taken any dual credit or advanced placement classes? Yes No If yes, what university/college did you attend? 17. Please list the post-secondary college(s) to which you have applied or been accepted (proof of acceptance is required for): School City State Orientation Date School City State Orientation Date UHSEP Application Revised January 16, 2015 HCOP Funded by HRSA-D18HP24088

4 FAMILY BACKGROUND Father/Guardian 1 (Required): Applicant lives with this parent/guardian: Yes 18. Name: No Last First Middle 19. Address: Street Address or P.O. Box Number City or Town County State Zip Code 20. Phone: Address: 21. Circle highest grade completed: Did your father/guardian attend college? Yes No 23. Please check the highest level of degree obtained? Associate Degree Bachelor s Degree Master s Degree Doctoral Degree Other 24. Occupation: 25. Employer: Mother/Guardian 2 (Required): Applicant lives with this parent/guardian: Yes 26. Name: No Last First Middle 27. Address: Street Address or P.O. Box Number City or Town County State Zip Code 28. Phone: Address: 29. Circle highest grade completed: Did your mother/guardian attend college? Yes No 31. Please check the highest level of degree obtained? Associate Degree Bachelor s Degree Master s Degree Doctoral Degree Other 32. Occupation: 33. Employer: 34. How many siblings do you have? 35. What is their range in age? 36. Have any of them attended college? Yes No If yes, how many? 37. Have any attended graduate/professional school? Yes No If yes, how many? 38. Do you have any relatives in a health profession? Yes No Which specific fields? FINANCIAL BACKGROUND 39. I am currently financially supported by (check all that apply): Self Father Mother Other (state relationship to you): 40. Total Annual Household Income: 41. How many people live in your household (include yourself)? 42. Number of children or dependents in your household (include ages): UHSEP Application Revised January 16, 2015 HCOP Funded by HRSA-D18HP24088

5 ADDITIONAL INFORMATION 43. Have you completed any other UNM HSC Office for Diversity programs (select all that apply)? Dream Makers/Dream Makers + HCA 44. How did you find out about this program? Instructor, Advisor Web Publications (websites, listserv) Office for Diversity Friend, Parent Flyer/brochure Other (specify): 45. Please list your health career interest(s): 46. Please list any health related certifications or training you have received and date of completion (i.e. CPR, First Aid): 47. Please list extra-curricular, volunteer, and/or community experiences: (i.e. sports, school clubs, church activities, etc.) 48. If applicable, please list any special needs or considerations you would like us to be aware of: 49. What size T-Shirt would you like? S M L XL 2-XL STATEMENT OF CERTIFICATION I certify that all information given is true to the best of my knowledge. I understand that failure to disclose accurate information is grounds for dismissal from or selection into the program. I agree to provide all necessary documentation. If accepted into the UHSEP Program, I understand that my participation is a major educational privilege that can impact my future, my family s future, and the future of healthcare in New Mexico. Signature of Applicant Date Signature of Parent/Guardian (If under age 18) Date UHSEP Application Revised January 16, 2015 HCOP Funded by HRSA-D18HP24088

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7 RECOMMENDATION FORM PLEASE RETURN THIS WITH YOUR APPLICATION To the Applicant Please fill in your name and high school on the lines below and give this information to the individual you have selected provide a recommendation for you. Applicant s Name Name of School To the recommending individual The student named above is applying to the UNM Health Sciences Center, Office for Diversity s Undergraduate Health Sciences Enrichment Program. This program provides an academic learning environment for entering college freshmen that are interested in a career as a healthcare professional. UHSEP was designed to meet the needs of New Mexico by educating youth to become competitive applicants to enter health professional schools. The program will challenge students with a rigorous curriculum in academic, social, and developmental support. This program seeks to identify students who demonstrate the following characteristics: Financial need; Academic performance or promise; Interest in pursuing a health related career; Strength of character, evidence of leadership potential, and emotional maturity and stability; The potential to contribute to one s community later in life. Please provide your contact information below, in the case that the Office for Diversity staff has any pending questions or concern. Recommender Name: Phone Number: Relationship to Applicant: To help in the selection of participants into the Undergraduate Health Sciences Enrichment Program, we ask that you please answer all of the following questions. Please limit your answers to the allotted space provided. ALL COMPLETED RECOMMENDATION FORMS MUST BE SUBMITTED IN A SEALED ENVELOPE TO THE STUDENT PRIOR TO THE APPLICATION DEADLINE OF FRIDAY, APRIL 10, How long and in what capacity have you known this applicant?

8 Please describe the applicant s strengths? Please comment on the applicant s area(s) of development. What efforts has the applicant made to improve? How has the applicant contributed above and beyond her/his expected responsibilities? Please use the following space to include any additional comments. (Optional) Please rate the applicant on the following categories: Cannot Recommend Below Above Excellent Academic Performance Leadership Qualities Emotional Maturity Reliability Ability to interact with adults and peer Professionalism Resiliency (Ability to overcome barriers)

9 RECOMMENDATION FORM PLEASE RETURN THIS WITH YOUR APPLICATION To the Applicant Please fill in your name and high school on the lines below and give this information to the individual you have selected provide a recommendation for you. Applicant s Name Name of School To the recommending individual The student named above is applying to the UNM Health Sciences Center, Office for Diversity s Undergraduate Health Sciences Enrichment Program. This program provides an academic learning environment for entering college freshmen that are interested in a career as a healthcare professional. UHSEP was designed to meet the needs of New Mexico by educating youth to become competitive applicants to enter health professional schools. The program will challenge students with a rigorous curriculum in academic, social, and developmental support. This program seeks to identify students who demonstrate the following characteristics: Financial need; Academic performance or promise; Interest in pursuing a health related career; Strength of character, evidence of leadership potential, and emotional maturity and stability; The potential to contribute to one s community later in life. Please provide your contact information below, in the case that the Office for Diversity staff has any pending questions or concern. Recommender Name: Phone Number: Relationship to Applicant: To help in the selection of participants into the Undergraduate Health Sciences Enrichment Program, we ask that you please answer all of the following questions. Please limit your answers to the allotted space provided. ALL COMPLETED RECOMMENDATION FORMS MUST BE SUBMITTED IN A SEALED ENVELOPE TO THE STUDENT PRIOR TO THE APPLICATION DEADLINE OF FRIDAY, APRIL 10, How long and in what capacity have you known this applicant?

10 Please describe the applicant s strengths? Please comment on the applicant s area(s) of development. What efforts has the applicant made to improve? How has the applicant contributed above and beyond her/his expected responsibilities? Please use the following space to include any additional comments. (Optional) Please rate the applicant on the following categories: Cannot Recommend Below Above Excellent Academic Performance Leadership Qualities Emotional Maturity Reliability Ability to interact with adults and peer Professionalism Resiliency (Ability to overcome barriers)

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