UNIVERSITY OF MICHIGAN MEDICAL SCHOOL
Diversity & Career Development Office (DCDO)
Profiles for Success
2013 Student Application
Program Dates May 20th – June 28th
CHECKLIST (For Your Own Use)
NOTE: Upon submission, all application materials will become the property of the University of
Michigan and will not be returned.
 Completed application forms (personal info, education history, MCAT, extra-curricular
activities, volunteer experience)
 Program qualification essay (to include any supporting documents)
 Short essay questions
 List of biology, chemistry, physics, math, English, sociology, and psychology course(s)
you have completed and/or are currently enrolled
 Recommendation reference list, forms (3) and letters (3)
Note: three letters of recommendation are required. Two letters should be from science
instructors/professors and the third can be from an individual of your choice
 A current resume or curriculum vitae
 Official college transcripts from each institution you have attended
 Sign all pages where required
ALL APPLICATION MATERIALS SHOULD BE SUBMITTED TO:
(Letters of recommendation and transcripts should be sent directly from the source to the address below)
Profiles for Success – Pre-Medical
UMMS Diversity & Career Development Office
Attn: Inel Lewis
2919C Taubman Medical Library (TML)
1135 Catherine Street
Ann Arbor, MI 48109-5603
Telephone: (734) 764-8185 or Fax: (734) 615-4828
Your application must be postmarked and mailed by February 4, 2013.
Remember, it is your responsibility to see that
ALL application materials are postmarked and mailed by the deadline.
UNIVERSITY OF MICHIGAN MEDICAL SCHOOL
Profiles for Success, 2013
UNIVERSITY OF MICHIGAN MEDICAL SCHOOL
PROFILES FOR SUCCESS (PFS)
DESCRIPTION:
Profiles for Success (PFS) is a seven week residential program from mid-May until end of June
designed for third-year, fourth-year and recent college graduates who are interested in the fields
of medicine or dentistry. The medical component of the program prepares students to navigate the
medical school admission process successfully, with activities including:




MCAT preparation in structured classes or facilitated study groups
Admissions procedures workshops are held to provide exposure to medical school requirements
American Medical College Application Service (AMCAS) process workshops including
personal essay writing
Mock interviews
Additionally, students are exposed to research, careers in medical education, and an in-depth review
of medical career specialties. Each student is assigned to a medical student mentor, and there are
formal and informal opportunities for participants to interact with faculty and staff.
PURPOSE:
The purpose of Profiles for Success (PFS) is to assist junior and senior level college students and
recent graduates through the admissions process for dental or medical school. Program participants
will also have an opportunity to increase their knowledge of career opportunities within dentistry or
medicine.
UNIVERSITY OF MICHIGAN MEDICAL SCHOOL
Profiles for Success, 2013
I. ELIGIBILITY
To participate in PFS, applicants must meet the following criteria:

College junior, senior, recent graduate, or individual making a career transition

Self-identify as educationally, socially, or economically disadvantaged OR
demonstrated commitment to serve underserved populations within the U.S. (see
detailed criteria on application)

Cumulative and science GPA of 3.0 or better

Completed the following courses:
o 2 Semesters of Biology with Labs
o 1 Semester of upper level Biology, if possible
o 2 Semesters of Inorganic Chemistry with Labs
o 2 Semesters of Organic Chemistry with Labs
o 2 Semesters of Physics with labs
o 1 Semester of Biochemistry
o 1 Semester of Math (i.e. Possibly Stats, Comp Science, Calculus)
o 2 Semesters English Composition
UNIVERSITY OF MICHIGAN MEDICAL SCHOOL
Profiles for Success, 2013
Completed applications must be postmarked and mailed by February 4, 2013.
II. PERSONAL INFORMATION
1. Name:
LAST
FIRST
M.I.
2. Date of Birth:
Age: _____
MONTH
DAY
YEAR
3. Birthplace
4. Citizenship: Applicants must be a US citizen or permanent resident to participate in the program (check one):
US Citizen
Permanent Resident
5. Email Address:
6. Name of School:
7. Current Mailing Address: Current address until
/
/
(PERSONAL/CAMPUS)
STREET
CITY, ST, ZIP
/
Phone: (Room/Mobile)
8. Permanent Home Address (where you can be reached after July 1, 2013):
STREET
CITY, STATE ZIP CODE
PHONE NUMBER
9. Please list the name and address of someone who will always know where you are at any
point in the future:
NAME
PHONE NUMBER
STREET
CITY, ST, ZIP
10. Name of Parent or Guardian:
11. Phone Number:
_____ _______
/
Land line
12. Gender:
 Female
13. Year in College: (circle one)
11. E-mail:
Cell Phone
 Male
 Other
1
2
3
4
14. Year you participated in U of M Summer Science Academy (if applicable):
15. Year you became a DCDO pre-med advisee (if applicable):
UNIVERSITY OF MICHIGAN MEDICAL SCHOOL
Profiles for Success, 2013
III. PROGRAM QUALIFICATIONS
Please provide the following information. Using the guidelines below to determine eligibility, check
the appropriate boxes that apply to you. Please submit a corresponding typed essay (2-3
paragraphs) to explain your eligibility. Only one category is necessary to qualify. Documentation is
not required at time of application submittal, but must be available upon request:
 Economically disadvantaged: A student who comes from a “low income family” with an
annual income below the thresholds published in the Federal Register by the Secretary, DHHS,
for use in all health professions programs (see page 8 for income guidelines).
 Educationally disadvantaged: A student who comes from a community college or a less
competitive four-year institution, as defined by Barron’s Profiles of American Colleges.
Standardized test scores (ACT/SAT) at student’s school are markedly below other institutions,
or student performance on standardized tests (ACT/SAT) is below national norms AND student
has an overall grade point average below 3.0 or a science grade point average below 2.90.
A student who attended secondary school in a financially designated poor district. Parents or
other adults in the household are not high school graduates.
A student who lacked the opportunity to gain academic enrichment from other sources.
 Socially disadvantaged: A student who comes from an environment that has inhibited (but not
prevented) him or her from obtaining the knowledge, skills and abilities required to enroll in,
and successfully complete an undergraduate course of study that could lead to a career in the
health sciences. This includes, but is not limited to: First generation college students, students
limited by their community setting (rural, inner city or reservation), students with a certified
learning and/or physical disability, students from a single-parent household, or students from a
foster-care setting for the majority of their K-12 experience.
 Demonstrated commitment to improving the health of the underserved and
disadvantaged populations: Personal life experiences with underserved communities and/or
experiences concerning disadvantaged health issues that have motivated you to pursue training
in dentistry/medicine. Significant volunteer or other work for a clinic or agency serving the
underserved or disadvantaged populations (local, national or international). Other experiences
(e.g. specific courses taken) which have prompted you to focus on improving the health of
underserved and disadvantaged populations.
I certify the information provided in this application is true to the best of my knowledge. If
needed, I will supply information to document my status as a student from a disadvantaged
background, or my demonstrated commitment to improving the health of underserved and
disadvantaged populations.
Signature:
Date:
UNIVERSITY OF MICHIGAN MEDICAL SCHOOL
Profiles for Success, 2013
Income Guidelines
The Secretary defines a “low-income family” for programs included in Titles III, VII and VIII of the
Public Health Service Act as having an annual income that does not exceed 200% percent of the
Department's poverty guidelines. 1“Section 673(2) of the Omnibus Budget Reconciliation Act
(OBRA) of 1981 (42U.S.C. 9902(2)) requires that the Secretary of Health and Human Services
(HHS) to update the poverty guidelines at least annually, adjusting them on the basis of the
Consumer Price Index for All Urban Consumers (CPI-U). The poverty guidelines are used as an
eligibility criterion by the Community Services Block Grant program and a number of other Federal
programs. These guidelines will remain in effect until HHS publishes the 2011 poverty guidelines,
which is expected in late January 2011.”
-----------------------------------------------------------------------2200% Income
Size of parents' family *
level **
-----------------------------------------------------------------------1.......................................................... $21,660
2...........................................................
29,140
3...........................................................
36,620
4...........................................................
44,100
5...........................................................
51,580
6...........................................................
59,060
7...........................................................
66,540
8...........................................................
74,020
-----------------------------------------------------------------------* Includes only dependents listed on Federal income tax forms. Some programs will use the
student's family rather than his or her parents' family.
** Adjusted gross income for calendar year 2012.
Dated: July 30, 2010.
Federal Register/ Vol. 75, No. 148/ Tuesday, August 3, 2010/Notices
2010 Poverty Guidelines- In accordance with section 1012 of the Department of Defense Appropriations Act of 2010, the poverty
guidelines published on January 23, 2009 will remain in effect until updated poverty guidelines are published in March 2010.
1
2
UNIVERSITY OF MICHIGAN MEDICAL SCHOOL
Profiles for Success, 2013
I. FAMILY INFORMATION
Father
1. Name:
LAST
FIRST
M.I.
2. Occupation:
3. Marital Status:
Married
Single
Widowed
Divorced
Separated
4. Education:
Less Than/Partial High School
BA/BS Degree
High School Graduate
Graduate School
Some College
Associates Degree
Professional School (specify)
Mother
1. Name:
LAST
FIRST
M.I.
2. Occupation:
3. Marital Status:
Married
Single
Widowed
Divorced
Separated
4. Education:
Less Than/Partial High School
BA/BS Degree
High School Graduate
Graduate School
Some College
Professional School (specify)
Associates Degree
UNIVERSITY OF MICHIGAN MEDICAL SCHOOL
Profiles for Success, 2013
II.
SHORT ESSAY
Please provide a short essay in which you introduce yourself, and address the following
questions: (word limit: 500)
What exposure have you had to the field of medicine and how has this influenced you?
What are your goals as a medical professional?
How would you describe yourself? How would others describe you?
Explain why you want to participate in this program and why we should select you as a
participant.
5. What unique skills, qualities or life experiences would you bring to the medical profession?
1.
2.
3.
4.
Attach your typed essay to the application, and include your name on each page of your essay.
Please save an electronic version of your answers to be used if you are accepted into the program.
I certify that the above information is true, complete and correct to the best of my knowledge. I
understand that falsifying or providing incorrect information may jeopardize my participation in this
or any other future University of Michigan Medical School Health Careers Summer Programs.
Signature:
Date:
UNIVERSITY OF MICHIGAN MEDICAL SCHOOL
Profiles for Success, 2013
III. EDUCATION HISTORY
Please list your high school and the most recent colleges or universities you have attended:
1.
High School:
City:
2.
State:
Zip:
State:
Zip:
Current College/University:
City:
College Standing (circle one): Junior
Senior
Recent
College Graduate
Major:
Total credit hours completed:
3.
Cumulative GPA:
Name of College/University:
City:
College Standing (circle one): Junior
Total credit hours completed:
_____
State:
Zip:
Senior
Recent
College Graduate
Cumulative GPA:
Have you taken course(s) in biology or chemistry? Please list these on the next page.
 Yes
 No
Have you taken any biology, chemistry, physics, math or English courses at other institutions?
 Yes (If yes, please have only those transcripts sent to the address provided)
 No
The following courses must be completed or in progress to participate in the pre-medical PFS
program (please note that students must have a cumulative and science GPA of 3.0 or higher to participate
in the program):
2 Semesters of Biology with Labs
1 Semester of upper level Biology, if possible
2 Semesters of Inorganic Chemistry with Labs
2 Semesters of Organic Chemistry with Labs
2 Semesters of Physics with labs
1 Semester of Biochemistry
1 Semester of Math (i.e. Possibly Stats, Comp Science, Calculus)
2 Semesters English Composition
UNIVERSITY OF MICHIGAN MEDICAL SCHOOL
Profiles for Success, 2013
Please list all Biology, Chemistry, Physics, Math, English, Sociology and Psychology course(s) you have
taken and/or are currently enrolled. Include grade received, and semester/term you took the course. Please
be advised that all program pre-requisites must be fulfilled prior to the program in order to qualify
for admission into PFS.
COURSE
SEMESTER COMPLETED
GRADE RECEIVED
UNIVERSITY OF MICHIGAN MEDICAL SCHOOL
Profiles for Success, 2013
Have you previously taken the Medical College Admissions Test (MCAT)?
 No, anticipated test date: _____/_____/_____
 Yes, date taken: _____/_____/_____
(List MCAT score and a attach a copy of your score report)
Physical Sciences Total Raw Score _____________
Verbal Reasoning Score _______________
Biological Sciences Score ________________________
Writing Sample Total Raw Score _________________________
Have you taken an MCAT review course?
 Yes, if yes, where? __________________________
 No
When do you plan to apply to medical school?_____________________________________
Extra-Curricular Activities:
List any extracurricular activities (sports, hobbies, clubs, etc.). You may use a separate sheet of
paper if necessary.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Have you ever participated in a health careers opportunity program or summer research program?
 No
 Yes, please list the name of the program, the location and dates attended:
________________________________________________________________________________
________________________________________________________________________________
__________________________________________________________________________
How did you hear about our program?




Friend
Advisor
Website
Other: _____________________________________________________________________
UNIVERSITY OF MICHIGAN MEDICAL SCHOOL
Profiles for Success, 2013
IV. REFERENCES
Three (3) letters of recommendation should be mailed directly from each person writing the
recommendation. Note: Two letters should be written by two different science instructors. One letter may
be written by an advisor, counselor, employer or other person of your choice.
List names and titles of the people you have asked to complete the 3 recommendation forms you received
with your application. YOUR REFERENCES SHOULD INCLUDE AT LEAST TWO DIFFERENT
SCIENCE INSTRUCTORS and ONE non-SCIENCE major.
1.
Name
Title
Institution
E-mail Address
2.
Name
Title
Institution
E-mail Address
3.
Name
Title
Institution
E-mail Address
UNIVERSITY OF MICHIGAN MEDICAL SCHOOL
Profiles for Success, 2013
RECOMMENDATION FORM
Student’s Name: ______________________________________________________________________
EVALUATOR: The University of Michigan School of Dentistry and Medical School hosts a seven-week
summer program, Profile for Success, which is designed to expose participants to health careers in dentistry
and medicine for the purpose of developing competitive applicants for dental and medical schools. Your
candid and thoughtful evaluation of the applicant is greatly appreciated. Please return this completed
form and attached letter of recommendation to the address below. Letters should be postmarked no
later than February 4, 2013.
Please circle the number that corresponds to your evaluation of this applicant in the categories listed.
Definition of Scale:
1=Excellent
2= Very Good
3=Fair
4=Poor
X=Inadequate Knowledge
Appearance & Presentation
1
2
3
4
X
Personality
1
2
3
4
X
Maturity & Judgment
1
2
3
4
X
Dependability & Reliability
1
2
3
4
X
Perseverance
1
2
3
4
X
Character & Integrity
1
2
3
4
X
Initiative
1
2
3
4
X
Self Esteem
1
2
3
4
X
Leadership
1
2
3
4
X
Potential as a Health Professional
1
2
3
4
X
Relationship to applicant?
___________________________________
Within your recommendation letter, please describe the student’s qualities, characteristics, and if
known, potential as a health care professional. Also, include any known academic weaknesses (testtaking, study skills, writing, etc.) to assist us in working with the student during the program.
Evaluator’s Name:
Position/Title:
PLEASE PRINT
Department: ____________________ School:_______________________________________
Evaluator’s Signature:
Date:
Please Return this Form to:
Profiles for Success
Attention: Inel Lewis, Career Development Programs Manager
University of Michigan Medical School
Diversity & Career Development Office
1135 Catherine Street
2919C Taubman Medical Library
Ann Arbor, MI 48109-5603
UNIVERSITY OF MICHIGAN MEDICAL SCHOOL
Profiles for Success, 2013
RECOMMENDATION FORM
Student’s Name: ______________________________________________________________________
EVALUATOR: The University of Michigan School of Dentistry and Medical School hosts a seven-week
summer program, Profile for Success, which is designed to expose participants to health careers in dentistry
and medicine for the purpose of developing competitive applicants for dental and medical schools. Your
candid and thoughtful evaluation of the applicant is greatly appreciated. Please return this completed
form and attached letter of recommendation to the address below. Letters should be postmarked no
later than February 4, 2013.
Please circle the number that corresponds to your evaluation of this applicant in the categories listed.
Definition of Scale:
1=Excellent
2= Very Good
3=Fair
4=Poor
X=Inadequate Knowledge
Appearance & Presentation
1
2
3
4
X
Personality
1
2
3
4
X
Maturity & Judgment
1
2
3
4
X
Dependability & Reliability
1
2
3
4
X
Perseverance
1
2
3
4
X
Character & Integrity
1
2
3
4
X
Initiative
1
2
3
4
X
Self Esteem
1
2
3
4
X
Leadership
1
2
3
4
X
Potential as a Health Professional
1
2
3
4
X
Relationship to applicant?
___________________________________
Within your recommendation letter, please describe the student’s qualities, characteristics, and if
known, potential as a health care professional. Also, include any known academic weaknesses (testtaking, study skills, writing, etc.) to assist us in working with the student during the program.
Evaluator’s Name:
Position/Title:
PLEASE PRINT
Department: ____________________ School:_______________________________________
Evaluator’s Signature:
Date:
Please Return this Form to:
Profiles for Success
Attention: Inel Lewis, Career Development Programs Manager
University of Michigan Medical School
Diversity & Career Development Office
1135 Catherine Street
2919C Taubman Medical Library
Ann Arbor, MI 48109-5603
UNIVERSITY OF MICHIGAN MEDICAL SCHOOL
Profiles for Success, 2013
RECOMMENDATION FORM
Student’s Name: ______________________________________________________________________
EVALUATOR: The University of Michigan School of Dentistry and Medical School hosts a seven-week
summer program, Profile for Success, which is designed to expose participants to health careers in dentistry
and medicine for the purpose of developing competitive applicants for dental and medical schools. Your
candid and thoughtful evaluation of the applicant is greatly appreciated. Please return this completed
form and attached letter of recommendation to the address below. Letters should be postmarked no
later than February 4, 2013.
Please circle the number that corresponds to your evaluation of this applicant in the categories listed.
Definition of Scale:
1=Excellent
2= Very Good
3=Fair
4=Poor
X=Inadequate Knowledge
Appearance & Presentation
1
2
3
4
X
Personality
1
2
3
4
X
Maturity & Judgment
1
2
3
4
X
Dependability & Reliability
1
2
3
4
X
Perseverance
1
2
3
4
X
Character & Integrity
1
2
3
4
X
Initiative
1
2
3
4
X
Self Esteem
1
2
3
4
X
Leadership
1
2
3
4
X
Potential as a Health Professional
1
2
3
4
X
Relationship to applicant?
___________________________________
Within your recommendation letter, please describe the student’s qualities, characteristics, and if
known, potential as a health care professional. Also, include any known academic weaknesses (testtaking, study skills, writing, etc.) to assist us in working with the student during the program.
Evaluator’s Name:
Position/Title:
PLEASE PRINT
Department: ____________________ School:_______________________________________
Evaluator’s Signature:
Date:
Please Return this Form to:
Profiles for Success
Attention: Inel Lewis, Career Development Programs Manager
University of Michigan Medical School
Diversity & Career Development Office
1135 Catherine Street
2919C Taubman Medical Library
Ann Arbor, MI 48109-5603