HOUSTON PREMEDICAL ACADEMY
Application Form 2016*
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You must apply to UH and UH Honors College prior to submitting this application.
Please use the UH ID number assigned to you as your ID number on this application.
Applicant Information
Applicant’s Full Name
Last
First
Middle
City
State/Zip
Address
Number and Street
Date of Birth
UH ID Number1
Home Phone ______________ Cell Phone ___________________
Other _______________
Student email address ___________________________
U.S. Citizen (circle):
Yes
No
Gender (circle):
M
F
If No, Resident Status (Attach documentation):
Ethnicity
Race
Will you be a first generation college student? (circle) YES/NO
Institutional Action/Explanation of Institutional Action
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Parent Information
Mother/Guardian’s Full Name
Last
First
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*Available as a WORD document on DHSHP website
Revised & Approved by BCM Office of Admissions 10/15
Middle
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Applicant UH ID Number
Address
Number and Street
City
Occupation ____________________________
State/Zip
Highest degree obtained __________________
Father/Guardian’s Full Name
Last
First
Middle
Address
Number and Street
City
Occupation ____________________________
State/Zip
Highest degree obtained __________________
Academic History
TO BE FILLED OUT BY THE REGISTRAR ONLY
Rank
Cumulative G.P.A.
Core G.P.A. (Eng., Math, Sci., Soc Sci. (ONLY)
English 1 (SS)
English 2 (SS)
Biology (SS)
Algebra 1 (SS)
U.S. History (SS)
*STAAR:
*SS=Scale
Score
TO BE FILLED OUT BY APPLICANT
SAT-Math
SAT-CR
SAT-W
M/C
Essay
Month/Yr. Taken
English
Math
Reading
Sci. Reas.
Composite
Writing (2-12)
**SAT
**ACT
**SS=Super score
Honors
1.
Please list the most significant honors, awards and achievements earned during your high school
career. (Type and limit your response to the space provided below.)
Name of Honor/Award
Basis for Honor/Award
Year Received
a.
b.
c.
d.
e.
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Applicant UH ID Number
Leadership/Community Service
2.
Please list high school, community organizations/ community service with which you have been
involved. Include the time period of involvement and any elected positions you may have held.
(Type and limit your response to the space provided below.)
Organization/Club
Elected Position
Time Period/
Hours of service
a.
b.
c.
d.
Employment/Internships/Summer Activities
3.
Describe of activities. (Type and limit your response to the space provided below.)
a.
b.
c.
d.
e.
f.
g.
Total Hours of Service Completed___________
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Applicant UH ID Number
Other Interests
4.
In the space below, tell us about who you are. Specifically, what background or story can you share
that is central to your identity? (Type and limit your response to the space provided below.)
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Applicant UH ID Number
5. List three issues that confront medicine today. Of the three, which is the most important and why?
(Type and limit your response to the space provided below.)
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Applicant UH ID Number
6. Describe an adversity that you have faced, how you managed to deal with it, and how the experience
affected you. (Type and limit your response to the space provided below.)
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Applicant UH ID Number
Authorization and Signature
I authorize the University of Houston to make available to Baylor College of Medicine all of my
admission application materials for the purpose of determining my eligibility for the Houston
Premedical Academy.
I certify that the information submitted in this application is complete and accurate to the best of my
knowledge and belief.
Signature
Date
Completed Application Packet due February 2, 2016 by 5:00pm. Must include: Houston Premedical
Academy application, University of Houston and UH Honors College application or letter of acceptance,
maximum of three Letters of Recommendation, and an Official Transcript. Incomplete applications will
not be reviewed by Baylor College of Medicine Admissions’ Committee.
Return Application Packet to:
Bernice Ochoa-Shargey, Ph.D.
Dean of Instruction
DeBakey High School for Health Professions
3100 Shenandoah
Houston, TX 77021
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