YSU-BaccMed Application—Spring 2016
This application assumes you have already applied to YSU and we have all your transcripts, high school and/or college.
General Information
Home Address:
Preferred Name:
Social Security Number:
Gender:
Date of Birth:
First Generation college student?
Lived here how long:
Home Phone:
Cell:
Email:
Signature:
Date:
Racial/Ethnic Background
Citizenship
Ethnicity:
American Indian or Alaska Native:
Asian or Pacific Islander:
Black or African American:
Hispanic:
Mainland Puerto Rican:
Mexican American:
White:
Unknown/Decline to respond:
Citizenship Status:
Ohio Resident:
Currently living in US:
Birth City:
Birth State:
Birth Country:
Permanent Resident/Visa
Note: “African-American” includes descendants of American
slaves as well as descendents of African immigrants.
Issue Date:
Expiration Date:
Visa Type:
Alien Registration Number:
Native Language:
High School
ACT Scores:
School:
Home Schooled:
Attended from:
Attended until:
Transcript GPA:
Class Rank:
Class Size:
Test Date:
Composite Writing Reading Science Math English
SAT Scores:
Test Date:
Composite Verbal Math Writing
Medical Professions/Interests: Check each in which
For Office Use Only:
Calculated GPA (4-point scale):
Calculated BCPM (4-point scale):
you are interested:
□ Primary Care
□ Medically Underserved Communities
□ Research related to, and supporting, primary care and
medically underserved communities
Parent 1
Parent 1
Relationship:
Name:
Email:
Employer:
Occupation:
Education:
Living:
Address:
City:
State:
Zip Code:
Country:
Address outside of US or Canada?
Relationship:
Name:
Email:
Employer:
Occupation:
Education:
Living:
Address:
City:
State:
Zip Code:
Country:
Address outside of US or Canada?
Extracurricular Activity I
Extracurricular Activity II
Type of Experience:
Date Range:
Hours:
Brief Description:
Type of Experience:
Date Range:
Hours:
Brief Description:
YSU-BaccMed Application—Spring 2016
This application assumes you have already applied to YSU and we have all your transcripts, high school and/or college.
Extracurricular Activity III
Extracurricular Activity IV
Type of Experience:
Date Range:
Hours:
Brief Description:
Type of Experience:
Date Range:
Hours:
Brief Description:
Extracurricular Activity V
Extracurricular Activity VI
Type of Experience:
Date Range:
Hours:
Brief Description:
Type of Experience:
Date Range:
Hours:
Brief Description:
ESSAYS
Essay 1
Have you ever held a part-time job? If so, please describe each such job and what you have learned from that experience.
YSU-BaccMed Application—Spring 2016
This application assumes you have already applied to YSU and we have all your transcripts, high school and/or college.
Essay 2
Describe your interest in primary care using specific examples. Primary care includes: family medicine, general internal
medicine, general pediatrics; medically underserved populations, including rural and urban communities; research directly
related to the above medical areas and underserved populations.
Essay 3
What is your view of healthcare access, and how is your view of medically underserved communities informed by your
experiences?