Program start date: June
Application Deadline: April 30, 2012
SUMMER ACADEMIC ENRICHMENT PROGRAM
APPLICATION
DEADLINE: APRIL 30, 2012
University of Texas Health Science Center – San Antonio- Lower Rio Grande Valley AHEC
The University of Texas at Brownsville and Texas Southmost College
I. PERSONAL INFORMATION
Please type (or print very neatly)
First, Middle, and Last Name:
Social Security Number:
Sex:
Date of Birth:
Age:
___ Female
___ Male
Mailing Address:
City:
State:
Zip code:
County:
E-mail Address:
Legal Address (if different than mailing):
City:
State:
Zip code:
County:
How long have you lived at this address? _____ years
Home Phone:
Cell Phone:
Are you a U.S. Citizenship
___Yes
Permanent Visa No.
___No (please indicate the type of visa and visa number below)
Student Visa No.
Other Visa No.
Place of Birth:
Ethnicity:
Father's Legal Name:
Father’s Level of Education:
Father’s Occupation:
Mother's Legal Name:
Mother’s Occupation:
How many brothers and sisters do you have? _____
Business phone:
Mother’s Level of Education:
Business phone:
Ages of each:
II. EDUCATIONAL INFORMATION
High School Attended _______________________ Overall GPA ____________
Science GPA _____________
*** ENCLOSE AN OFFICIAL COPY OF YOUR MOST RECENT HIGH SCHOOL TRANSCRIPT ***
LRGV AHEC
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Program start date: June
Application Deadline: April 30, 2012
III. OTHER INFORMATION
a.) What percentage of your college expenses (tuition, room and board, and other living expenses) were provided by the following sources.
Please account for 100%.
a. Family
_______ %
b. Student Loan
_______ %
c.
Scholarship
_______ %
d. Jobs/Employment
_______ %
e. Other
_______ %
TOTAL
100%
b.) Did you file an income tax return last year?
______ No
______ Yes (if yes, select the income range reported)
___ less than $10,000
___ $10,001 - $20,000
___ $20,001 - $30,000
___ $30,001 - $40,000
___ $40,001 - $50,000
___ over $50,001
c.) Did your parents claim you as a dependent on either of the last two year’s income tax returns?
______ No
______ Yes (if yes, provide your parent’s please indicate their income range)
___ less than $10,000
___ $10,001 - $20,000
___ $20,001 - $30,000
___ $30,001 - $40,000
___ $40,001 - $50,000
___ over $50,001
d.) Has your education or vocation ever been interrupted for any reason? Please explain the reason or causes for the interruption or how
you avoided an interruption.
e.) How did you learn about this program?
f.) Please describe your participation in educational SCIENCE activities. (Include college and high school summer programs, clubs, fairs,
etc.)
LRGV AHEC
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Program start date: June
Application Deadline: April 30, 2012
h.) Please explain briefly your participation in NON-SCIENCE activities. (Include college and high school athletics, band, clubs, theater, etc.)
i.) List your work experiences over the last 3 to 5 years.
j.) Language spoken at home most of the time _______________________________
Do you consider yourself proficient in a language other than English _____No
_____Yes
If yes, what language__________________
IV. PERSONAL STATEMENT/ESSAY
ATTACH A SEPARATE PAGE EXPLAINING, IN YOUR OWN WORDS, THE DEVELOPMENT OF YOUR INTEREST IN HEALTH
PROFESSIONS (e.g. medicine, dentistry, nursing, medical research, and others) AND YOUR REASONS FOR WANTING TO BECOME A
HEALT PROFESSIONAL.
If applicable, indicate any special experiences, unusual factors or other information not previously included which you feel the program
admission committee should consider when reviewing your application.
V. EVALUATION
Provide ONE LETTER OF RECOMMENDATION in support for your participation in this program. Please have your evaluator seal your
recommendation letter in an envelope to submit with your application. Your evaluator may Email your evaluation to cherie.gallardo@utb.edu
I understand that the selection committee for this preparation course does not regard applications
complete until supporting documents have been received. These include transcripts, personal
statement, and a letter of evaluation to be submitted along with your application.
I certify that the above information submitted is complete and correct to the best of my knowledge and
belief.
_______________________________________________________________
Signature
Mail completed application with transcripts to:
LRGV AHEC
___________
Date
Office of Premedical Education Programs
University of Texas at Brownsville
and Texas Southmost College
80 Fort Brown
Brownsville, TX 78520
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