LaHSEP Track III
Latino Health Science Enrichment Pre-Medicine Program
Summer 2014 Application
Early admissions deadline: May 9, 2014
General admissions deadline: June 13, 2014
For more information please contact:
Annette De La Torre
Program Coordinator
1200 W. Harrison 2640 SSB (MC 220)
Chicago IL. 60607-7164
adelat2@uic.edu
312-996-3356
LaHSEP Summer 2014 Track 3
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LaHSEP Track III Goals:
The Hispanic Center of Excellence in Medicine (HCOE) in partnership with the Latin American
Recruitment and Educational Services program (LARES) at the University of Illinois at Chicago
(UIC) is offering a summer academic enrichment program for incoming first year students. This
summer academic enrichment program provides participants the opportunity to engage in current
research, develop Math and English skills and also learn about college transition and resources on
the UIC campus. The program will take place from Monday, June 23, 2014 to Friday, August 1,
2014: Monday –Friday 9:00am-3:30pm at UIC.
PLEASE USE CHECKLIST TO COMPLETE YOUR APPLICATION
Eligibility/Requirements
Current High School Senior
Must have an interest in pre-medicine
Applied and admitted to UIC
Submitted UIC intent to enroll form by May 1st
Completed UIC placement exams & place into college level English 160 and Math 090
or above
Complete all sections of the application including a two page double spaced essay
LaHSEP Summer 2014 Track 3
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PERSONAL INFORMATION:
DATE: __________
Name: _____________________________________________________________________
First
Middle
Last
UIN number: ______________
Date of Birth: ___/____/___
Permanent Address (Home): __________________________________________________
City: _________________________
State: _________
Zip Code: _________
Current Address (Academic Year) _______________________________________________
City: _________________________
State: _________
Zip Code: _________
Cell Phone: ___________________
Home Phone: ____________________
UIC E-Mail: ____________________
Personal E-mail: _____________________
Gender: ___ Female ___Male
U.S Citizen _____
Permanent Resident _____
Alien Registration Number____________
Race/Ethnicity: Check all that apply.
___ American Indian or Alaskan Native
___ Cuban
___ Asian
___Mexican
___ African American or Black
___ Puerto Rican
___ White not of Hispanic Origin
___ Native Hawaiian or Pacific Islander Latino/Hispanic (specify) ________________
___ Other (specify) ___________________
LaHSEP Summer 2014 Track 3
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HOUSEHOLD INFORMATION:
Father’s Name: _________________________________________________________
Living: ____ Deceased: _____
Occupation: ____________________________________________________________
Education Level Completed: _______________________________________________
Mothers Name: _________________________________________________________
Living: ____ Deceased: _____
Occupation: ____________________________________________________________
Education Level Completed: _______________________________________________
FAMILY ANNUAL GROSS INCOME
Indicate below your family annual gross income.
Less than $9,999 ____
$20,000-$24,999 ____
$35,000-$39,999 ____
$49,000-higher
____
$10,000-$14,999 ____
25,000-$29,999 ____
$40,000-$44,999 ____
$15,000-$19,999 ____
$30,000-$34,999 ____
$45,000-$48,999 ____
COMMUNITY ENVIRONMENT
Please check the community size in which you have resided for the majority of your life.
____Rural (pop. <2,000)
____Small city (pop. <1000,000)
____Suburb of medium city
____Suburb of large city
____Small town (pop. <20,000)
____Medium urban/city (pop. 100,000-500,000)
____Large city/urban (pop. >500,000
WHAT COMMUNITY DO YOU LIVE IN? (i.e. Pilsen, Lincoln Park, Little Village)?
______________________________________________________________________________________
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EDUCATIONAL INFORMATION:
High School attended (Name, City, State) ____________________________________________
Year of Graduation: ________ ACT score: ________ SAT score: ________
High School cumulative GPA Unweight: _____
Weighted: _____
UIC Intended Major: _______________________________
Are you a fluent speaker in another language other than English? ______________________
If so, what language? ______________________________________
List all other post-secondary institutions where you have been enrolled and courses completed
List all AP/ISB courses completed with scores
SERVICE AND ACTIVITY INFORMATION:
Please list all extracurricular activities, volunteer work and leadership positions held. The
information provided in this section will be considered during the selection process.
Name of Organization/Event Dates ___ / ___ /___
LaHSEP Summer 2014 Track 3
Leadership Position
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COMMUNITY AND OTHER VOLUNTEER ACTIVITIES:
Organization/Event Dates ___/ ___ / ___
WORK EXPERIENCE:
Location
Date ___ / ___ / ___
Position/Hr per week
PERSONAL STATEMENT:
Please include a two page statement detailing how the LaHSEP track 3 program can help you
achieve your academic career goals. This statement is one of the most important components of
the application.
Your personal statement should include the following:
 Involvement in community and or volunteer work
 Your personal and professional goals
 How you became interested in a health career
 Why you believe you are an excellent candidate for the program
**The essay should be two doubled-spaced typed pages. Submit your personal statement along with
complete application form.
LaHSEP Summer 2014 Track 3
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LaHSEP Track III
Latino Health Science Enrichment Program
Summer 2014 Application
I hereby certify that the information contained on this application is complete and correct. I
understand giving false information will disqualify my application.
______________________________________________
Date: ___ / ___ / ___
Signature of applicant
SUBMIT APPLICATION:
Applications must be submitted and received electronically via email to adelat2@uic.edu by
11:59pm or mailed to the address listed below. To be considered for early admissions please
submit application by May 9, 2014, and for general admissions by June 13, 2014. Please be sure
to include your personal statement with your application. Any application that is not typed and/or
missing supporting documents will not be considered.
Submit complete application to:
Annette De La Torre
Program Coordinator
Latin American Recruitment and
Educational Services (MC 220)
1200 W. Harrison 2640 SSB (MC 220)
Chicago IL. 60607-7164
LaHSEP Summer 2014 Track 3
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Recommendation Form
Applicant Information:
First Name: _____________________ Middle Initial: ________ Last Name: ____________________
School: ___________________________________________________ _______________________
School Address: _______________________________________________________________
Number and Street
City
State
Zip code
How do you know the applicant? _____________________________________________________
Recommenders Name (please print clearly) ____________________________ Title: _____________
Recommender’s signature: __________________________________________ Date: ___ /___ / ___
Recommenders email: ____________________________
phone: ( _____)_______________________
Area code
Number
Ext.
Use the following scale to rate the applicant:
5=Excellent
4=Good
3=Average 2=Fair 1=Poor
Circle appropriate response:
Communication skills
5
4
3
2
1
NA
Disciplined work habits
5
4
3
2
1
NA
Ability to master concepts
5
4
3
2
1
NA
Preparedness for class
5
4
3
2
1
NA
Class participation
5
4
3
2
1
NA
Willingness to learn
5
4
3
2
1
NA
Listening skills
5
4
3
2
1
NA
How well does the student work with others?
5
4
3
2
1
NA
Maturity level of student
5
4
3
2
1
NA
Motivation
Attendance
Attendance
5
4
3
2
1
NA
5
4
3
2
1
NA
Additional comments:
__ I highly recommend this applicant
__ Recommend applicant with reservations
__ Recommend applicant
__ Not recommended
LaHSEP Summer 2014 Track 3
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