PLEASE PRINT CLEARLY OR TYPE
HealthSuccess Application
2013 – 2014
INSTRUCTIONS: Please submit your completed application, essay, and middle/high school
transcript to: NEOMED Enrollment Services, 4209 State Route 44, P.O. Box 95, Rootstown, Ohio
44272 by July 26, 2013. *Students must have at least a 3.5 cumulative GPA to be considered.*
NAME: ______________________________________________________________________
ADDRESS: ___________________________________________________________________
CITY: _________________________________
STATE: _______ ZIP: ____________
STUDENT’S E-MAIL: _________________________________________________________
PARENT’S/GUARDIAN’S E-MAIL: _____________________________________________
NOTE: ALL communication about programming throughout the year will be via e-mail. A valid
professional e-mail address is required for the student and a parent/guardian that will be checked
often. (ex:James_B_Smart@hotmail.com) Please list two working contact phone numbers.
COUNTY: ________________________________________________________________________
HOME PHONE: ______ -_______ - __________ CELL PHONE: ______ -_______ - __________
DATE OF BIRTH: ______/______/_________
MALE □
FEMALE □
OTHER □
RACE/ETHNICITY (Please circle the ONE that applies best. If not specified then please list.):
African American or Black
Caucasian or White
Egyptian
American Indian or Alaskan Native
Asian or Pacific Islander
Arab American
Mexican American
Puerto Rican
Other Asian
Other Hispanic
Two or More Races
Decline to Respond
Native Hawaiian or Other Pacific Islander
Not Specified __________________________________
HEALTH CARE AREA(S) OF INTEREST:
□ Medicine
□ Pharmacy
□ Other ___________________________
Mother’s/Parent’s/Guardian’s Highest Level of Education:
□ K-12 □ Some College □ Associate □ Bachelors □ Graduate/Professional □ Other ___________
Father’s/Parent’s/Guardian’s Highest Level of Education:
□ K-12 □ Some College □ Associate □ Bachelors □ Graduate/Professional □ Other ___________
PLEASE PRINT CLEARLY OR TYPE
HIGH SCHOOL: _____________________________________________________________
HIGH SCHOOL ADDRESS: ___________________________________________________
H.S. GRADUATION YEAR: ______________
CURRENT GPA: _________
GEOGRAPHICAL AREA IN WHICH YOU LIVE:
□ Urban □ Suburban □ Rural □ Inner City □ Other
ARE YOU A PAST MEMBER OF HEALTHSUCCESS? □ Yes □ No
If so, when? __________________________________________________________________
WERE YOU A PARTICIPANT IN MEDCAMP? □ Yes □ No
If so, when? __________________________________________________________________
ARE YOU A PAST OR CURRENT MEMBER OF HIP, UPWARD BOUND, OTHER
PIPELINE PROGRAM/ENRICHMENT? □ Yes □ No
If so, when? __________________________________________________________________
ARE YOU CURRENTLY INVOLVED WITH ANY ACTIVITIES THAT WILL PREVENT
YOU FROM BEING IN ATTENDANCE AT HEALTHSUCCESS EVENTS? □ Yes □ No
If so, what? __________________________________________________________________
HOW DID YOU FIND OUT ABOUT THE HEALTHSUCCESS PROGRAM?
□ Past participant in HealthSuccess
□ Guidance Counselor
□ Participated in MedCamp
□ Science Teacher
□ NEOMED Office of Enrollment Services
□ NEOMED Web site
□ Friend/Family Member
□ Other, please specify:
______________________________________
ESSAY: Attach a short essay (maximum: one page, single spaced, 12-point font) explaining why you
wish to participate in the HealthSuccess program. Please include past science or health care related
experience that would make you a better contributor to this program. This may also include any
extracurricular activities you have been involved in or any honors you have been awarded.
I certify, to the best of my knowledge, that the information herein is true. I understand that any
misrepresentation of the facts on this application is cause for refusal of admission or dismissal from the
program.
Applicant’s Signature: ___________________________________________Date: __________
Parent’s/Guardian’s Signature: ___________________________________Date: __________
Postmark Deadline: Friday, July 26, 2013
Be sure to submit ALL of the following materials to complete your application:
Application Form
Essay
Middle School Report Card / High School Transcript (3.5 Cumulative GPA Required)
NEOMED is an equal opportunity/affirmative action educator and employer.