1 HEALTH CAREERS ACADEMY- Silver City, NM PROGRAM DATES ...

HEALTH CAREERS ACADEMY- Silver City, NM PROGRAM DATES: JUNE 12, 2015 – JULY 24 2015 APPLICATION DEADLINE: 5:00PM, FRIDAY, APRIL 10, 2015 Heath Careers Academy (HCA) is an intense and rewarding six-week, residential program, hosted at Western New Mexico University in partnership with the University of New Mexico Health Sciences Center Office for Diversity and Hidalgo Medical Services, for high school students who will be sophomores, juniors and seniors during the 2015 – 2016 academic year. HCA is designed for New Mexico residents who are interested in pursuing a health career. The program is also designed to enhance math, science, language and critical thinking skills while exposing students to health and science related professions. This program will challenge students by balancing a rigorous academic curriculum, ACT preparation, service learning, and health science 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. Due to stipend payments, 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 2.25 on a 4.0 scale • Must be a current freshman, sophomore or junior in high school, current seniors are encouraged to apply to Undergraduate Health Science Enrichment Program (UHSEP) • 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 be on campus from 8:00am to 4:00pm (tentatively), Monday through Friday, during the specified time period. 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. 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 entire application. ALL COMPLETED APPLICATIONS MUST BE SUBMITTED VIA DESCRIPTIONS 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: http://hsc.unm.edu/programs/diversity/index.shtml Mail to: UNM HSC Office for Diversity MSCO8 4680 1 University of New Mexico Albuquerque, NM 87131-0001

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

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2015 HCA Application Revised February 13, 2015 HCOP Funded by HRSA-D18HP24088

HEALTH CAREERS ACADEMY 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 is acceptable ¨ 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 in spite 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.

Office Use Only Date Submitted: Staff Initials:

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HEALTH CAREERS ACADEMY SILVER CITY, NEW MEXICO 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:

2.

Address:

Last

First

Middle

Street Address or P.O. Box Number City or Town

County

State

3.

Phone:

4.

Student ID or UNM Banner (if applicable):

5.

Gender:

□ Female □ Male

6.

U.S. Citizen:

□ Yes

7.

New Mexico Resident:

8.

Date 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):

Zip Code

Email Address:

□ No

If no, can you provide a SSN or ITIN:

□ Yes

□ No

□ Yes

□ No

If no, state of residency: 9. Place of Birth:

□ 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 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 Pre-ACT/ACT? □Yes □No What was your composite score?

Test Date:

15.

Have you taken the PSAT/SAT? □Yes □No What was your composite score?

Test Date:

16.

Have you taken any dual credit or advanced placement classes?

□ Yes

□ No

If yes, what university/college did you attend?

3


FAMILY BACKGROUND Father/Guardian 1 (Required): Applicant lives with this parent/guardian: □ Yes 17.

Name:

18.

Address:

Last

□ No

First

Middle


County

19.

Phone:

20.

Circle highest grade completed: 1

21.

Did your father/guardian attend college?

22.

Please check the highest level of degree obtained?

State

Email Address:

□ Associate Degree 23.

Occupation:

24.

Employer:

2

3

4

5

6

7

8

□ Yes

□ Bachelor’s Degree

9

10

11

Name:

26.

Address:

12

□ No

□ Master’s Degree

Mother/Guardian 2 (Required): Applicant lives with this parent/guardian: □ Yes 25.

Zip Code

Last

□ Doctoral Degree

□ Other

□ No

First

Middle


County

27.

Phone:

28.

Circle highest grade completed: 1

29.

Did your mother/guardian attend college?

30.

Please check the highest level of degree obtained?

State

Zip Code

Email Address:

□ Associate Degree

2

3

4

5

□ Bachelor’s Degree

6

7

8

□ Yes

9

10

11

12

□ No

□ Master’s Degree

□ Doctoral Degree

31.

Occupation:

32.

Employer:

33.

How many siblings do you have?

34.

What is their range in age?

35.

Have any of them attended college?

□ Yes

□ No

If yes, how many?

36.

Have any attended graduate/professional school?

□ Yes

□ No

If yes, how many?

37.

Do you have any relatives in a health profession?

□ Yes

□ No

Which specific fields?

□ Other

FINANCIAL BACKGROUND 38.

I am currently financially supported by (check all that apply): □ Self

□ Father

□ Mother

□ Other (state relationship to you):

39.

Total Annual Household Income:

40.

How many people live in your household (include yourself)?

41.

Number of children or dependents in your household (include ages):

4


ADDITIONAL INFORMATION 42.

Have you completed any other UNM HSC Office for Diversity programs (select all that apply)? □ Dream Makers/Dream Makers + □ HCA

43.

How did you find out about this program? □ Office for Diversity

□ Friend, Parent

□ Instructor, Advisor □ Flyer/brochure

□ Web Publications (websites, listserv) □ Other (specify):

44.

Please list your health career interest(s):

45.

Please list any health related certifications or training you have received and date of completion (i.e. CPR, First Aid):

46.

Please list extra-curricular, volunteer, and/or community experiences: (i.e. sports, school clubs, church activities, etc.)

47.

If applicable, please list any special needs or considerations you would like us to be aware of:

48.

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 HCA 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

Date

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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 Health Careers Academy Program. This program’s purpose is to give interested students exposure in the many health careers offered at the UNM Health Sciences Center. Students will also enhance their math, science, language, and critical thinking skills. The program will challenge students by balancing a rigorous academic curriculum, ACT preparation, service learning, and health career exploration. 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 Health Careers Academy 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 Academic Performance Leadership Qualities Emotional Maturity Reliability Ability to interact with adults and peer Professionalism Resiliency (Ability to overcome barriers)

Below Average

Average

Above Average

Excellent

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 Health Careers Academy Program. This program’s purpose is to give interested students exposure in the many health careers offered at the UNM Health Sciences Center. Students will also enhance their math, science, language, and critical thinking skills. The program will challenge students by balancing a rigorous academic curriculum, ACT preparation, service learning, and health career exploration. 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 Health Careers Academy 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 Academic Performance Leadership Qualities Emotional Maturity Reliability Ability to interact with adults and peer Professionalism Resiliency (Ability to overcome barriers)

Below Average

Average

Above Average

Excellent