PREP PROGRAM

Document Sample
PREP PROGRAM Powered By Docstoc
					                           The UMDNJ - School of Osteopathic Medicine
              2009 Summer Pre-Medical Research Education Program (PREP) Application
Instructions: Please type or print clearly in black ink. Complete all sections of the application. Enclose or forward a
transcript of all college course work with the application and mail to the address below. Letters of recommendation
should be mailed by the person(s) completing the form to the same address. Please ensure that all materials reach our
office no later than the application deadline of Friday, February 20, 2009.


Personal Information

    1.   Name: Last_______________________________ First__________________________ Middle__________
    2.   Current Mailing Address:     Street____________________________________________________________
         City_______________________________ State____________________ Zip__________
    3.   Permanent Mailing Address: Street___________________________________________________________
         City_______________________________ State____________________ Zip__________
         Email Address: _____________________________________
    4.   Home Phone: (_____)_________________                  Cell Phone: (_____) _______________________
    5.   Date of Birth: __________________
    6.   Birthplace: City____________________________ County_____________________ State______________
    7.   Please Check:     □ MALE        □ FEMALE
         U.S. Citizen: □ YES      □ NO     If No, please state country of citizenship:   ___________________
         Permanent Resident: □ YES        □ NO        New Jersey Resident: □ YES         □ No
    8.   Marital Status: □ Single □ Married      □ Divorced □ Separated
    9.   Ethnic/Racial Self-Description: ____________________________________________
   10.   Do you have a physical disability that requires specially designed instructional materials or programs, modified
         physical facilities, or related services to enable full participation in and access to the PREP program at
         UMDNJ-SOM? □ NO □ YES (please explain) ______________________________________________
   11.   Father’s/Guardian’s Name __________________________ Phone (___) _____________
   12.   Address: Street _______________________City ______________ State ____ Zip _____
   13.   Occupation _____________________________________________________________
   14.   Mother’s/Guardian’s Name _________________________ Phone (___) _____________
   15.   Address: Street _______________________City_______________ State ____Zip_____
   16.   Occupation _____________________________________________________________
   17.   Education Level: Father _____________________ Mother _______________________
   18.   How many siblings do you have? ____________________
   19.   Please list their ages: _____________________________________________________
   20.   Did any of them attend college: ______No ______Yes          If Yes, please indicate the college(s) below:
Educational Information

21.    What educational institution are you presently attending? ___________________________________________
22.    Are you a participant in your school’s Educational Opportunity Fund (EOF) program? Check: □ YES         □ NO
23.    What year are you in school? ________________________________                   GPA (cumulative)____________
24.    What is your Major? _________________________________                Minor: ____________________________
25.    List courses you are currently enrolled in:
       _____________________________________________________________________
       _____________________________________________________________________
       _____________________________________________________________________
       _____________________________________________________________________

26.    List any extracurricular activities you participate in (sports, hobbies, clubs, etc.):
       _____________________________________________________________________
       _____________________________________________________________________

27.    Do you have an advisor? ____No _____Yes     If Yes, please indicate the person’s name and title:
       _____________________________________________________________________________________

28.    How did you learn about the PREP program? ________________________________________________

29.    Have you ever participated in a summer enrichment program? _____No _____Yes   If Yes, indicate the
       name and location of the program: ___________________________________________________________

30. List names, addresses and titles or occupations of two persons you have asked to complete the recommendation
    forms you received with your application:
      Name ____________________________ Title or Occupation ______________________
      Address _________________________________________________________________
      Name ____________________________ Title or Occupation ______________________
      Address _________________________________________________________________

31. Please write a short narrative on a separate sheet of paper in which you introduce yourself. Explain your
    interest in medicine, why you want to participate in the Summer PREP program, and why you would make an
    excellent participant.

I certify that the above information is complete and true to the best of my knowledge.

Your Signature ______________________________________________                      Date ___________________________


                Please return to:            Summer PREP Program
                                             UMDNJ - School of Osteopathic Medicine
                                             Academic Center, Suite 210
                                             One Medical Center Drive
                                             Stratford, NJ 08084
                                             Phone: 856-566-6196
                                             Fax: 856-566-6341
                          The UMDNJ - School of Osteopathic Medicine
                  2009 Summer Pre-Medical Research Education Program (PREP)
                                        Academic Center, Suite 210
                                        One Medical Center Drive
                                           Stratford, NJ 08084

                                  RECOMMENDATION FORM

INSTRUCTIONS:
This form must be completed by a pre-medical advisor, academic advisor, or science faculty
member. Please have the individual completing this form return it directly to the above address.

The applicant must sign this form below before giving it to the recommender for completion under
the provision of the Family Education Rights and Privacy Act (Buckley Act).



       I waive any right of access that I might have to this recommendation form.


       Applicant's Signature and Date



       I do not waive any right of access that I might have to this recommendation form.


       Applicant's Signature and Date



Full Name of Applicant:


Last                                  First                                 Middle

Evaluator: Please give your candid assessment of this applicant. Feel free to attach a letter in
addition to the checklist provided. Specific descriptions of the individual's strengths and
weaknesses are most valuable to the Selection Committee. Responses to the following questions
can also assist the selection process: Does the applicant possess the academic potential for pursuit of
medical studies? How would you rate the applicant’s potential versus other students you have
worked with? What personal characteristics of this applicant make her/him an outstanding
candidate for the PREP program? Thank you for your participation in our evaluation process!
Please use checkmarks in the table below to rate the applicant according to your observation
or knowledge.


                                 Outstanding   Excellent   Satisfactory   Fair   Poor   No knowledge
                                                                                        or opportunity
                                                                                        to observe
Academic Performance




Class Preparedness/Attendance




Effort & Perseverance




Self motivation




Handles counseling or critique




Communications Skills
(verbal & written)
Teamwork/Ability to work with others
Aptitude for a career in clinical medicine or bio-medical research




Judgment/Maturity




Facility w/ computers, laboratory equipment, etc.




Contributes to school/department community




Leadership skills




Intellectual curiosity/ability




Analytical/ problem-solving skills
In what capacity have you known this student? __________________________________________
How long have you known this student? _______________________________________________


Printed name of person completing recommendation:_____________________________________
Title:____________________________________________________________________________
Institution: _______________________________________________________________________
Signature: _______________________________________________________________________
Date: ___________________________________________________________________________
                          The UMDNJ - School of Osteopathic Medicine
                  2009 Summer Pre-Medical Research Education Program (PREP)
                                        Academic Center, Suite 210
                                        One Medical Center Drive
                                           Stratford, NJ 08084

                                  RECOMMENDATION FORM

INSTRUCTIONS:
This form must be completed by a pre-medical advisor, academic advisor, or science faculty
member. Please have the individual completing this form return it directly to the above address.

The applicant must sign this form below before giving it to the recommender for completion under
the provision of the Family Education Rights and Privacy Act (Buckley Act).



       I waive any right of access that I might have to this recommendation form.


       Applicant's Signature and Date



       I do not waive any right of access that I might have to this recommendation form.


       Applicant's Signature and Date



Full Name of Applicant:


Last                                  First                                  Middle


Evaluator: Please give your candid assessment of this applicant. Feel free to attach a letter in
addition to the checklist provided. Specific descriptions of the individual's strengths and
weaknesses are most valuable to the Selection Committee. Responses to the following questions
can also assist the selection process: Does the applicant possess the academic potential for pursuit of
medical studies? How would you rate the applicant’s potential versus other students you have
worked with? What personal characteristics of this applicant make her/him an outstanding
candidate for the PREP program? Thank you for your participation in our evaluation process!
Please use checkmarks in the table below to rate the student according to your observation or
knowledge.


                                 Outstanding   Excellent   Satisfactory   Fair   Poor   No knowledge
                                                                                        or opportunity
                                                                                        to observe
Academic Performance




Attendance/Class Preparedness




Effort & Perseverance




Self-motivation




Handles counseling or critique




Communications Skills
(verbal & written)
Teamwork/Ability to work with others
Aptitude for a career in clinical medicine or bio-medical research




Judgment/ Maturity




Facility with computers, laboratory equipment, etc.




Contributes to school/department community




Leadership skills




Intellectual curiosity/ability




Analytical/problem-solving skills
In what capacity have you known the applicant? ________________________________________
How long have you known the applicant? _____________________________________________


Printed name of person completing the recommendation:__________________________________
Title:____________________________________________________________________________
Institution: _______________________________________________________________________
Signature: _______________________________________________________________________
Date: ___________________________________________________________________________