2016 MED Program
Application
Instructions for Submission
Please complete this part of the application, and return it to the UNC School of Medicine, Office of
Special Programs, via email attachment to medprogramunc@gmail.com with attention line
“[First Initial, Last Name] - 2016 MED Application Part II” (Example: J. Doe - 2016 MED Application).
All parts of the MED application are due on Tuesday, January 19, 2016 at 4pm.
Please see checklist below.
APPLICATION CHECKLIST
Online
☐ Part I 2016 MED Program Application
Via email attachment
☐ Part II 2016 MED Program Application
Via mail in one packet as hard copies (postmarked by Tuesday, January 19, 2016)
UNC School of Medicine
Office of Special Programs
c/o MED Program
505 Berryhill Hall
CB# 7530
Chapel Hill, NC 27599
☐ OFFICIAL CUMULATIVE TRANSCRIPTS from all post-secondary institutions attended.
☐ At least two LETTERS OF EVALUATION from advisors or instructors familiar with your
academic background and personal motivation (preferably at least one from a science faculty
or instructor).
☐ UPDATED RESUME OR CV. Please include any health-related activities, academic honors,
academic program participation, research, academic honors, awards, or other recognitions
as well as work experience.
☐ FINANCIAL FORM(S) (Optional, if claiming financial disadvantage status)
A copy of your Student Aid Report (SAR Report) [generated from your Financial Aid Form
(FAFSA)] or your most recent tax form and/or your parents’ (if claimed as a dependent) for
verification purposes.
Contact
If you have any questions about the application, please contact the Office of Special Programs.
Email: medprogramunc@gmail.com | Office Phone: (919) 966-7673
2016 MED Program
Application
PERSONAL
First Name
Middle Name
Last Name
When did you submit Part I of the 2016 MED Program Application? Click here to enter a date.
To which MED Track are you applying? Choose one. ☐ Medical
☐ Dental
Please indicate a telephone number and usual times we can contact you to discuss questions we
may have regarding your application.
ACTIVITIES
Have you applied to health professional school(s) within the past three years?
☐ Yes
☐ No
If you answered yes to the question above, please provide the following information:
Health profession(s):
☐ Allopathic Medicine
☐ Osteopathic Medicine
☐ Dentistry
☐ Other
Year(s) of application:
☐ 2015
☐ 2014
☐ 2013
Results of
application
process
1
2016 MED Program
Application
What are your alternative plans for next fall? If you are graduating this year or are currently
not in school, what are your overall plans and strategy for competing for admission to health
professional school if you are not successful in the current application cycle?
Please indicate other summer programs to which you are currently applying.
Your response will not affect our review of your application.
How did you learn about the MED Program?
If someone referred you to the program, please share the individual(s) name(s).
2
2016 MED Program
Application
FAMILY BACKGROUND
Father
Mother
Step-Parent / Guardian
(if applicable)
Occupation
Category
(select dropdown)
Choose an item.
Choose an item.
Choose an item.
Education
Category
(select dropdown)
Choose an item.
Choose an item.
Choose an item.
Marital Status
(select dropdown)
Choose an item.
Choose an item.
Choose an item.
Deceased /
Unknown
Choose an item.
Choose an item.
Choose an item.
Retired / Disabled
Choose an item.
.Choose an item.
Choose an item.
Name
Occupation
Post-Secondary
Schools Attended
Degree(s)
obtained
Residence (City,
State, Country)
3
2016 MED Program
Application
FINANCES
If you do not claim socio-economic disadvantage status, sections A and B are optional.
If you are claiming socio-economic disadvantage status:
1) Complete ALL information for sections A and B, including requested questions for parents
as well as step-parent/guardian, even if person is not with the family at the present time.
2) Provide a copy of one of the following: (a) your Free Application for Federal Student Aid
(FASFA) or (SAR) form or (b) you or your parents (if you are claimed as a dependent) most
recent tax form (1040A) for verification purposes.
Types of Scholarships
Received
scholarship(s)?
Need-based
Choose an item.
Merit-based
Choose an item.
Other
Choose an item.
List Name of Scholarship(s) Received
Annual Income (Gross)
Father
Mother
Step-parent or Guardian
Your individual income
Spouse’s annual income
Number of siblings
Age(s) of sibling(s) that are…
In the home
Independent
Currently in college (including yourself)
Number of other dependents living with the family
4
2016 MED Program
Application
FINANCES (continued)
Marital Status
Choose an item.
If other, please explain.
If married, is spouse…
Choose an item.
If working, specify occupation.
If other, please explain.
Do you have children?
Choose an item.
Number of children
Ages of children
Children living with you
Choose an item.
Please give any additional explanation you wish concerning your financial circumstance or
disadvantage status.
ESSAY #1
5
2016 MED Program
Application
The MED Program seeks to bring applicants together for a summer who will learn
from and contribute to the program. Please provide a personal statement that
describes what your journey has been up to this point which may include
motivations, vision, experiences, and challenges, and includes any other pertinent
information you feel will help us gain and overall picture of who you are. This may
include outside activities, interests, or any discrepancies in your application. Your
statement is limited to page 7 (FONT: Times New Roman, Font Size 12, Single
Spaced). Anything past one page will not be read.



Why MED?
What have you done to prepare yourself for MED and your journey to professional
school?
How have those experiences changed you?
PLEASE ANSWER PROMPT ON PAGE 7.
ESSAY #2
In today’s global society, how important is it to be culturally sensitive and have a
clear understanding of what diversity is as a health care provider? Give us examples
of experiences you have personally witnessed, been involved in, or from current
events that come to mind to explain why. Your statement is limited to page 8. (FONT:
Times New Roman, Font Size 12, Single Spaced). Anything past one page will not be
read.
PLEASE ANSWER PROMPT ON PAGE 8.
6
2016 MED Program
Application
ESSAY #1 Response
7
2016 MED Program
Application
ESSAY #2 Response
8
2016 MED Program
Application
Community Standards Form
In an effort to maintain a safe learning community, we must ask the following questions of all enrolling
students. An answer of “yes” to one or more of the following questions will not necessarily preclude your
being enrolled. However, your failure to provide complete, accurate, and truthful information will be
grounds to dismiss you before or after enrollment.
For the purpose of the following questions, “crime” or “criminal charge” refers to any crime other than a
traffic-related misdemeanor or an infraction. You must, however, include alcohol or drug offenses
whether or not they are traffic-related.
If you answer “yes” to any of the questions below (1-4), you are required to provide your own written
explanation of the event(s) and a copy of the final disposition of your case.* If a copy of the final
disposition of your case is not available then you must submit a statement from your legal representative
summarizing the event(s).
1)
Have you been convicted of a crime?
2)
Have you entered a plea of guilty, a please of no contest, a please of nolo
contendere, or an Alford please, or have you received a deferred
prosecution or prayer for judgment continued, to a criminal charge?
Choose an item.
3)
Have you otherwise accepted responsibility for the commission of a crime?
Choose an item.
4)
Do you have any criminal charges pending against you?
Choose an item.
Choose an item.
If you answer “yes” to any of the following questions (5-7), you are required to attach an explanation and
any other documentation* requested below.
5)
Have you ever served a detention or been dismissed, suspended (in-school
or out-of-school), expelled, placed on probation, or otherwise subject to any
disciplinary sanction by any high school, college, or university? This may
include, but is not limited to, academic cheating, conduct violations, or
alcohol policy infractions. If you answer “yes”, you are required to attach
your explanation of the event, as well as a statement regarding the event
from an appropriate school official.
6)
Since graduating from high school, have you been out of school for any
reason other than routine vacations, disability-related reasons, or schoolrelated activities? If so, please provide on a separate sheet of paper a
detailed explanation (including a timeline) of how you spent your time since
graduating from high school.
7)
Have you received any type of discharge from military service other than an
honorable discharge?
Choose an item.
Choose an item.
Choose an item.
9
2016 MED Program
Application
Community Standards Form (continued)
You must promptly notify the admissions office in writing of any criminal charge, any disposition of a
criminal charge, or any school, college, or university disciplinary action against you, or any type of
military discharge other than an honorable discharge, or any non-routine absence from school that occurs
at any time after you submit this application. Your failure to do so will be grounds to deny or withdraw
your admission, or to dismiss you after enrollment.
*If you previously submitted an explanation or additional documentation with your application, you do
not need to submit these items again.
Read and sign the following statement: We cannot continue your enrollment without your signature.
I certify that the information provided on this form is complete and accurate. I authorize the Office of
Special Programs to make reasonable inquiry if any doubt should arise. I understand my failure to provide
complete, accurate, and truthful information on this form will be grounds to withdraw my admission, or
dismiss me after enrollment. I further understand that I am required to notify the Office of Special
Programs of any change in my mail or e-mail addresses.
☐
Checking this box represents your signature.
Date Signed
Click here to enter a date.
End of Part II 2016 MED Application
10