Clínica Tepati
University of California, Davis School of Medicine
Department of Family Practice
Summer 2015 Membership Application
Please complete the following questions thoughtfully. To ensure that Clínica Tepati continues to
grow and provide a valuable experience for our members, we have a thorough selection process.
Subsequent to completing and submitting the application online to: clinicatepatiucd@gmail.com,
you will receive an automated email response confirming we have received your application. If
you are selected for an interview you will receive an email or phone call by your interviewers
with details regarding the time and location of your interview. All interviews will be
conducted on Thursday, May 21st. This is a formal interview so please dress professionally. By
Tuesday, May 26th you will receive an email from the personnel manager informing you of our
decision. If you have any questions email clinicatepatiucd@gmail.com.
Honesty Policy- Policies applying to campus activities, organizations and stuedents (PACAOS): Students are
members of both society and the University community, with attendant rights and responsibilities. Students are
expected to comply with all laws and with University policies and campus regulations
Applications are due Tuesday, May 19th by 10:00AM
Applications received after 10:00AM will NOT be considered.
*PLEASE RESPOND TO EACH QUESTION IN RED FONT!*
Name:
Number of Quarters left at UC Davis:
Which summer session can you volunteer:
SS1 or SS2? Or Both?
Number of times applied to Clínica Tepati prior to tonight?
Telephone Number:
Preferred E-Mail Address:
Translator:
Training Date (June 13th, June 27th, or August 1st):
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**PLEASE RESPOND TO THE FOLLOWING QUESTIONS THOROUGHLY**
1) What motivated you to pursue a volunteer position at Clínica Tepati? (Please limit
to 250 words)
2) List past work experiences, activities, special training and/or courses that you think
might be of benefit to Clínica Tepati. Please specify the dates and number of hours
per week you committed to each activity. (Add rows as needed, cannot exceed one
page length)
Work Experiences,
Activities, Clubs,
Training, Course, etc.
Brief Description
(25 word limit)
Dates
Involved &
# of Hours
3) Based on one of your previous experiences, tell us about a time where you have done
more than what was expected of you? (Please limit to 250 words)
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4) How would you describe your ability to work as part of a team? Provide two
examples. (Please limit to 250 words)
5) Scenario: Imagine you were placed in a group of 7 students to carry out a project.
If 2 of your group members are not doing their part, what would you do to alleviate
the situation? How would you respond to the group members’ actions? (Please limit
to 150 words)
6) Describe a situation where you have worked under pressure or had a great deal of
stress and explain how you dealt with it. (Please limit to 250 words)
7) Are you proficient in other languages besides English? If so, please list other
languages and the level of proficiency in reading, writing and speaking. (Add rows
as needed)
Language
Proficiency in Reading
Proficiency in Writing
Proficiency in Speaking
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8) Given that summer volunteer positions with Clinica Tepati usually last only one
summer session (3 Saturdays), what steps will you take to contribute to Clinica
Tepati patients during your limited time? (Please limit to 250 words)
9) Would you be interested in becoming a permanent Clinica Tepati volunteer Fall
2014? Specify any reasons that would stop us from considering you as a volunteer
i.e. not having a 2.7 GPA, work commitments, prior academic commitments, etc.
Provide specifics as necessary. (When we review your performance after the
summer (if you were admitted), we will review your response to this question. Please
limit to 500 words)
10) Please complete the weekly schedule below, by listing all the courses you are
currently taking along with other activities you are also currently involved in (i.e.
other organization, tutoring, job, research, internship, etc.) (Please include
everything)
SUN
MON
TUES
WED
THUR
FRI
SAT
8 AM
9 AM
10 AM
11 AM
12 PM
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1 PM
2 PM
3 PM
4 PM
5 PM
6 PM
7 PM
8 PM
9 PM
10 PM
THANK YOU FOR APPLYING TO CLINICA TEPATI! 
IMPORTANT NOTICE:
Please convert you application into a PDF file. Applications not
converted to PDFs will NOT BE CONSIDERED.
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