PRE-MATRICULATION ENRICHMENT PROGRAM by bestt571

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        PRE-MATRICULATION ENRICHMENT PROGRAM
  LOUISIANA STATE UNIVERSITY HEALTH SCIENCE CENTER

                          Office of Multicultural Affairs
  P.O. Box 33932                                                     Tel: (318) 675-5049
  Shreveport, LA 71130-3932                                          Fax: (318) 675-4332

                         APPLICATION REQUIREMENTS

The Pre-Matriculation Enrichment Program (PEP) is sponsored by the Office of Multicultural
Affairs at the Louisiana State University Health Sciences Center- Shreveport. The PEP is a six-
week preparatory program that introduces students to three basic science courses (Anatomy,
Physiology and Biochemistry) which are taught in the first and second year of medical school. In
addition, students will be exposed to Study Skills and Operating Room techniques. The program
is schedule to begin June 1, 2010 through July 9, 2010.



A. DIRECTIONS:
    1. Please type or print in black ink.

    2. Complete ALL sections of the application. Any space(s) left blank will render the
       application incomplete and delay processing.

    3. Description of Disadvantaged Status (Refer to Section D).

    4. Please check the application to ensure accuracies: social security number, birth date,
       mailing address and telephone number(s).

    5. The application must be received by the March 31, 2010 deadline.

    6. Program information and the application can be downloaded at:




         http://www.sh.lsuhsc.edu/multicultural/front.htm



                    APPLICATION DEADLINE- March 31, 2010
                               PRE-MATRICULATION ENRICHMENT PROGRAM                              For Office Use Only
                                                                                                 Rec’d_________________
                                                                                                 GPA__________________
                           LOUISIANA STATE UNIVERSITY HEALTH SCIENCE CENTER                      Confirmation Letter_____
                                                                                                 Transcript_____________
                                                                                                 Accepted [ ]    Rejected [ ]

                                                Student Application Form

B. Personal Information – Please Type or Print Legibly
DATE: ______________________ SSN #: ________________________ GENDER: [ ] Male [ ] Female
NAME: ___________________________________________________________________________________
                  (Last)                   (Maiden)               (First)                                  (Middle)

MAILING ADDRESS: ______________________________________________________________________
                               P.O. Box or Street                           City         State                  Zip

AGE:_________       DOB ___________________            LOUISIANA RESIDENT: [ ] YES [ ] NO, state_____
MARITAL STATUS: [ ] Single [ ] Married, NAME OF SPOUSE:________________________________
HOME TELEPHONE: ___________________________CELL PHONE #:____________________________
NAME OF MOTHER : ___________________________TELEPHONE:______________________________
NAME OF FATHER : ___________________________TELEPHONE:_______________________________

PERSON(S) WITH WHOM YOU LIVE_____________________________RELATIONSHIP____________

TELEPHONE:__________________
CURRENT UNIVERSITY _____________________________ ADVISOR____________________________
CLASSIFICATION_______________________________GRADUATION DATE______________________
IF GRADUATED LIST UNIVERSITY AND DEGREE: ___________________________________________
                                            Race/Ethnicity (check one)
[ ] African American                                         [ ] Caucasian American
[ ] Asia American                                            [ ] Hispanic American
[ ] Native American                                          [ ] Other


Please describe your hometown by checking one of the following areas:
     [ ] Rural (Population less than 2,500)
     [ ] Urban (Population 2,500 or more)
Pipeline Participation:
 • Have you participated in the Jumpstart Summer Enrichment Program? [ ] NO [ ] YES, year ________
 • Have you participated in the Undergraduate Apprenticeship Program? [ ] NO [ ] YES, year ________
 • Have you participated in the Educational Familiarization Program? [ ] NO [ ] YES, year ________
                       Pre-Matriculation Enrichment Program
Participant's Name ______________________________________________________________

 C. Check below all courses you have completed.

 []   General Biology I                   []   Human Anatomy
 []   General Biology II                  []   Microbiology
 []   General Chemistry I                 []   Genetics
 []   General Chemistry II                []   Histology
 []   Physics I                           []   Physiology
 []   Physics II                          []   Biochemistry
 []   Organic Chemistry I                 []   Organic Chemistry I Lab
 []   Organic Chemistry II                []   Organic Chemistry II Lab

                    List other science and math courses taken
                                               COURSE      CREDIT
                  COURSE NAME
                                               NUMBER      HOURS




 EXPERIENCE: Community service/Volunteerism
 __________________________________________________________________
 __________________________________________________________________
 __________________________________________________________________

 Clinical/Medical: Shadowing/Research
 __________________________________________________________________
 __________________________________________________________________

 Extracurricular Activities: Honors/Awards/Recognitions
 __________________________________________________________________
 __________________________________________________________________
 __________________________________________________________________

 Scholarship(s):
 __________________________________________________________________
 __________________________________________________________________
 __________________________________________________________________
 __________________________________________________________________
 __________________________________________________________________
                         Pre-Matriculation Enrichment Program

D. Disadvantaged Criteria:
  A disadvantaged student may belong to one or all of the categories listed below regardless of
  ethnicity.

  1. Economic Disadvantage: Is based on parental or personal income and the number and
     age of dependents in a household as established by federal guidelines:
                                     2008 HHS Poverty Guidelines

                            Persons               48 Contiguous
                     in Family or Household       States and D.C.    Alaska    Hawaii

                                 1                    $10,400        $13,000   $11,960

                                 2                     14,000         17,500   16,100

                                 3                     17,600         22,000   20,240

                                 4                     21,200         26,500   24,380

                                 5                     24,800         31,000   28,520

                                 6                     28,400         35,500   32,660

                                 7                     32,000         40,000   36,800

                                 8                     35,600         44,500   40,940

                     For each additional
                                                       3,600          4,500     4,140
                     person, add


         SOURCE: Federal Register, Vol. 73, No. 15, January 23, 2008, pp. 3971–3972


  2. Educational Disadvantaged:
      • Students with limited proficiency in English
      • Students with poor standardized testing skills
      • Students living with parents or grandparents with limited formal education

  3. Social Disadvantaged:
      • Students residing in a single-parent household (income based)
      • Students residing in a rural community
      • Students residing in public housing or utilizing public assistance

  4. Non-Disadvantaged: Students who do not meet any of the above criteria, but would
     benefit from participation may apply.

   Family Annual Income Level: Check the appropriate box for your family’s or
      personal income level. If this section is left blank the application will be rendered
      incomplete and processing will be delayed.
         Less than $ 7,990.00 per year                             $ 20,001 to $ 30,000 per year
         $ 8,000 to $ 10,000 per year                              $ 30,001 to $ 50,000 per year
         $ 10,001 to $ 15,000 per year                             $ 50,001 to $ 70,000 per year
         $ 15,001 to $ 20,000 per year                             $ 70,001 to $ 100,000 per year

                           _________________________________
                                        Signature
                          Pre-Matriculation Enrichment Program
Participant's Name _____________________________________________________________


E. Disadvantaged Status: Please describe how you consider yourself disadvantaged using
the disadvantaged guidelines in the application. If you are non-disadvantaged indicate by writing
"Non-disadvantaged" in the space below. Your status will not limit your eligibility for
program participation.

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I understand that this application is for the Pre-Matriculation Enrichment Program (PEP)
use only. I give permission to the Office of Multicultural Affairs to use my photograph in
advertisements which promotes the PEP program.

                              _____________________________
                                         Signature


                             Office of Multicultural Affairs
                          Attention: Shirley Roberson, Director
                                     P.O. Box 33932
                           Shreveport, Louisiana 71130-3932

								
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