High School Information for Jane Marie Doe
NOTE: For each category, list experiences in reverse chronological order (i.e. most recent first); insert additional rows as needed. Detailed instructions for
completing this form may be obtained at http://www.xula.edu/premed/PMInfo/a.FRMeetings/a.BHCWorkshops/FR1.HowToDoHSInfoSUMMER.htm.
High School Name: Elksgrove Senior High
City, State:
Elksgrove, LA
Class Rank:
1
Number in Class:
275
Year Graduated: 2015
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ACADEMIC EXPERIENCES
Mark “Yes” column with “X” or “√” for any which apply:
Yes
Valedictorian?
X
Salutatorian?
National Merit Scholar?
National Merit Semi-finalist?
Nat. Achievement Scholar?
X
Nat. Achieve. Semi-finalist?
Yes
Who’s Who?
National Merit Commended?
Nat. Achieve. Recognized?
Yes
X
List any AP, IB, or other similar courses you took while in high school:
Type (AP, IB, Other)
Name of Course
AP
US History
AP
Computer Science
IB
Psychology
List any college courses taken while in high school:
Name of Course
College/University Attended (School Name and City, State)
Introduction to Sociology
Southeastern Louisiana University, Hammond, LA
Basic Statistics
Nunez Community College, Chalmette, LA
Year Attended
2014
2013
List on and off-campus academic organizations (e.g. honor societies, quiz bowl, etc.) to which you belonged while in high
school:
Academic Organization
Dates (Year to Year)
Office Held (if any)
Mu Alpha Theta
2014-2015
National Honor Society
2013-2015
Chapter President
High IQ Quiz Bowl
2012-2014
List on and off-campus academic awards/recognition (e.g. scholarships, honor roll, etc.) you received while in high school:
Academic Award
Year(s) Awarded
Xavier University of Louisiana St. Katharine Drexel
2015
Scholarship
Ebony Magazine Top Black High School Senior
2015
Award
Honor Roll
2011-2015
Loyola University New Orleans Full-Tuition
2014
Academic Scholarship
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Premedical Office, Xavier University of Louisiana
1
High School Information for Jane Marie Doe
NOTE: For each category, list experiences in reverse chronological order (i.e. most recent first); insert additional rows as needed. Detailed instructions for
completing this form may be obtained at http://www.xula.edu/premed/PMInfo/a.FRMeetings/a.BHCWorkshops/FR1.HowToDoHSInfoSUMMER.htm.
NON-ACADEMIC EXPERIENCES
List on and off-campus non-academic organizations (e.g. student council, band, team activities, chorus, cheerleading,
church, etc.) to which you belonged while in high school:
Non-Academic Organization
Dates (Year to Year)
Office Held (if any)
Art Club
2013-2015
President
Cheerleader
2011-2015
Captain
New Faith Community Church Youth Choir
2011-2015
Speech and Debate
2012-2013
List on and off-campus non-academic awards/recognition (e.g. service award, homecoming court, MVP, etc.) you received
while in high school:
Non-Academic Award
Year(s) Awarded
New Faith Church Youth Ministry Award
2015
Senior Prom Queen
2015
Speech and Debate Award
2013, 2012
Art in Motion Contest (1st place)
2012
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COMMUNITY SERVICE/VOLUNTEER EXPERIENCES
List on and off-campus community service/volunteer experiences that you engaged in while in high school:
Organization
Dates
Medical/Clinical?
(If “Yes” put “X” or “√”)
(Year to Year)
Children’s Hospital of Elksgrove
2013-2015
X
(Emergency Room Volunteer)
Habitat for Humanity
2013-2105
Junior League of Elksgrove
2012-2015
Elksgrove College Biology Department
2012-2014
(Research Volunteer)
American Red Cross
2011-2013
Elksgorve Nursing Home
2011-2012
X
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PAID EMPLOYMENT
List any paid employment that you engaged in while in high school:
Organization
Dates
Position
(Year to Year)
Elksrove College Biology Department
2014-2015
Research Assistant
Macy’s Department Store
2013-2015
Sales Associate
Houston’s Restaurant
2012-2014
Hostess
Private Tutor (Math, English)
2011-2013
Tutor
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Premedical Office, Xavier University of Louisiana
2
High School Information for Jane Marie Doe
NOTE: For each category, list experiences in reverse chronological order (i.e. most recent first); insert additional rows as needed. Detailed instructions for
completing this form may be obtained at http://www.xula.edu/premed/PMInfo/a.FRMeetings/a.BHCWorkshops/FR1.HowToDoHSInfoSUMMER.htm.
OTHER RELEVANT EXPERIENCE NOT LISTED ELSEWHERE
List any other on and off-campus experiences (e.g. certifications, research, enrichment programs, etc.) that you engaged in
while in high school and did not list elsewhere:
Organization/Experience
Dates
(Year to Year)
Certified Nursing Assistant
2014-2015
CPR Certification
2014-2015
Physician Shadowing (Elkgrove Pediatrics)
2011-2015
Premedical Office, Xavier University of Louisiana
3