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,
http://som.unm.edu/education/md/apply/residency.html. 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 [email protected] or by calling 505-272-2728 or toll free 1-866-494-0064.
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, 2015. 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 12th. 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, 2015. 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, 2015. 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, 2015. 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, 2015. FAXED APPLICATIONS WILL NOT BE ACCEPTED.
SUBMIT COMPLETE APPLICATION BY APRIL 10, 2015: Apply Online at:
http://hsc.unm.edu/programs/diversity/index.shtml Mail to:
UNM HSC Office for Diversity MSCO8 4680
1 University of New Mexico
Deliver in person to:
UNM Health Science Center, UNM North Campus Office for Diversity
2015 UHSEP Application Revised January 16, 2015 HCOP Funded by HRSA-D18HP24088
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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 12th. 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, 2015. 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, 2015. 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.
UNDERGRADUATE HEALTH SCIENCES ENRICHMENT PROGRAM
STUDENT APPLICATION
PERSONAL INFORMATION
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: Email 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):
□ Asian □ Black or African American □ Native Hawaiian/Pacific Islander □ White □ Other (Please specify):
11. What was your first language?
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:
School Name City and State Dates of Attendance Cumul. GPA High School:
College:
13. Current Grade Level:
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
2015 UHSEP Application Revised January 16, 2015 HCOP Funded by HRSA-D18HP24088
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FAMILY BACKGROUND
Father/Guardian 1 (Required): Applicant lives with this parent/guardian: □ Yes □ No 18. Name:
Last First Middle
19. Address:
Street Address or P.O. Box Number
City or Town County State Zip Code
20. Phone: Email Address:
21. Circle highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 22. 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 □ No 26. Name:
Last First Middle
27. Address:
Street Address or P.O. Box Number
City or Town County State Zip Code
28. Phone: Email Address:
29. Circle highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 30. 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:
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
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:
Email:
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, 2015.
How long and in what capacity have you known this applicant?
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 Average Average Above Average Excellent Academic Performance Leadership Qualities Emotional Maturity Reliability
Ability to interact with adults and peer Professionalism
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:
Email:
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, 2015.
How long and in what capacity have you known this applicant?
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 Average Average Above Average Excellent Academic Performance Leadership Qualities Emotional Maturity Reliability
Ability to interact with adults and peer Professionalism
