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UNC School of Medicine Student National Medical Association APPLICATION FORM

Application deadline: November 20, 2009 H-PREP Health Professions Recruitment Exposure Program Sponsored by The UNC School of Medicine Chapter of the Student National Medical Association Student Name

Grade _____________

Address _________________________________________________________________________________ City___________________________________________________ ZIP Code ________________________ Phone number __________________ High School_______________________________ G.P.A.__________ Sex _________

Race (optional) ________________

Email ___________________________

A. Please list the science courses you have taken: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

B. Does your school offer any advanced courses (Honors, AP, IB)? If so, which courses have you taken? ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

C. Please list any extracurricular activities: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Page | 1


UNC School of Medicine Student National Medical Association D. Would any of these activities prevent you from attending HPREP lectures and workshops? ________________________________________________________________________________________ E. Please list any awards or honors that you have received: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

F. In the space provided, please respond to the following questions: DO YOU HAVE AN INTEREST IN THE HEALTH CARE PROFESSIONS (NURSING, DENTISTRY, MEDICINE, ETC.)? IN YOUR OPINION, HOW WOULD THIS PROGRAM ENHANCE YOUR PREPARATION TO PURSUE THAT CAREER? ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Page | 2


UNC School of Medicine Student National Medical Association

I realize that H-PREP is a program that requires my full participation and attendance. I will commit to attending all scheduled meetings unless extenuating circumstances prevent my attendance. In the event that I am unable to attend a session, I will notify my teaching assistant immediately. I promise to put forth a great effort to get the most out of this unique and worthwhile experience. Student Signature_________________________________________ Date________________________ After reviewing the information concerning H-PREP, I understand the effort and time commitment required of my child and hereby give my permission for him/her to participate in the Health Professions Recruitment Exposure Program throughout the following seven Saturdays beginning January 30, 2010 until March 13, 2010. I realize that the cost of the program is free, including breakfast and lunch for each session, and I only have to provide transportation to and from the UNC School of Medicine for my child each Saturday. Parent/Guardian signature_____________________________________________________________________ Parent/Guardian Name (Print):_______________________________________Date_______________________

* Don’t forget to include sealed letter of reference from faculty from your school with the application or to inform faculty member to mail their reference form in separately.

DEADLINE: November, 20, 2009 Mail Application Materials to: Health Professions Recruitment Exposure Program c/o Student National Medical Association UNC School of Medicine Office of Educational Development 329 MacNider Bldg., CB#7530 Chapel Hill, NC 27514-7530

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UNC School of Medicine Student National Medical Association NOTE TO THE APPLICANT: This form should be

Health Professions Recruitment Exposure Program c/o Student National Medical Association UNC School of Medicine Office of Educational Development 329 MacNider Bldg., CB#7530 Chapel Hill, NC 27514-7530 (919) 966-7673

provided to a high school faculty member who will submit a reference. Please complete your name and address information

Due Date: November, 20, 2009

H-PREP LETTER OF REFERENCE Applicant Name: ______________________________________________________________________ Address: ______________________________________________________________________________ City, State, Zip Code: ___________________________________________________________________ Note to Respondent: The Health Professional Recruitment Exposure Program (H-PREP) is designed to expose motivated minority students to health topics as they relate to minority populations. Students selected to participate will attend a series of seven Saturday morning sessions and complete an individual as well as group project focused on a specific health issue in order to successfully complete the program. Please use this form to provide an evaluation of the student and return it to the student signed and sealed. Access to this form will be only to the applicant selection staff of this program. Timely completion of this form will be appreciated by both the applicant and the selection committee. Name of Respondent: ___________________________________________________________________ Name of High School: ___________________________________________________________________ High School Address: ___________________________________________________________________ Length of Time Associated with Applicant: _________________________________________________ Association of Respondent to Applicant: ____________________________________________________ Please rate the applicant in the following areas below. Mark an X where you deem appropriate. Below Average

Average

Good

Very Good

Outstanding

Exceptional

Academic Performance Interest in Science Maturity and Emotional Stability Ability to Express Self Coherently Ability to Relate to Others Effectively Page | 4


UNC School of Medicine Student National Medical Association

Health Professions Recruitment Exposure Program

Letter of Reference Applicant Name (Last, First, Middle): __________________________________________________________ Please use the space below for more specific comments as to how this student would benefit from a program such as HPREP.

Signature_______________________________________________

Date_______________________ Page | 5


UNC HPREP Application 2010