1 NEW MEXICO CLINICAL EDUCATION PROGRAM

NEW MEXICO CLINICAL EDUCATION PROGRAM
PROGRAM DATES: JUNE 15, 2015 – JULY 24, 2015
APPLICATION DEADLINE: 5:00 PM, FRIDAY, APRIL 10, 2015 5:00 PM, FRIDAY, APRIL 24, 2015
The New Mexico Clinical Education Program (ClinEd) is a six-week summer program for pre-professional college
undergraduate and graduate students who wish to apply to the UNM School of Medicine and are seeking to gain rural
clinical experience. The program provides experiences in rural clinical settings by placing students in primary care
facilities and community health centers throughout New Mexico. Students shadow clinicians and participate in all
aspects that the clinic and the community offer.
Interested applicants must be New Mexico residents, as defined by the UNM School of Medicine,
http://som.unm.edu/education/md/apply/residency.html. Preferably, underrepresented in medicine and come from
economically and/or educationally disadvantaged backgrounds. Applicants should demonstrate a commitment to increasing
health equity.
Applicants accepted in to our HEALTH NM pipeline programs must have a Social Security Number (SSN) or
Individual Tax Identification Number (ITIN).
Questions regarding citizenship, residency and/or application details can be directed to [email protected] or by
calling 505-272-2728 or toll free 1-866-494-0064.
Eligibility Requirements
• Pre-medical student currently in college as a junior, senior, or graduate
• Minimum 3.0 Science GPA on a 4.0 scale
• Previous MCAT score
• Ability to live in a rural community for 6 weeks
Participation Dates
Prior to make final selections, applicants will join Office for Diversity staff and partners in a formal interview that will take
place the week of April 27, 2015. Program staff will contact those individuals selected for an interview to schedule a time to
meet. The applicants selected to be part of ClinEd will be required to attend an orientation the week of June 8, 2015. Exact
dates and times will be included in the acceptance packet. The program will begin on Monday, June 15, 2015 and end on
Friday, July 24, 2015. Student participation is expected throughout the duration of the program.
Failure to include any of the supporting documents, not following directions completely, or leaving blank sections on this
application form will result in an automatic disqualification. Additionally, failure to meet the April 10, 2015 April 24, 2015
deadline will result in automatic disqualification. To apply, please complete the attached application.
ALL COMPLETED APPLICATIONS MUST BE SUBMITTED VIA DESCRIPTIONS LISTED BELOW BY 5:00PM
ON APRIL 10, 2015 BY 5:00PM ON APRIL 24, 2015 OR POSTMARKED ON OR BEFORE APRIL 10, 2015 APRIL
24, 2015. FAXED APPLICATIONS WILL NOT BE ACCEPTED.
SUBMIT COMPLETE APPLICATION BY April 10, 2015 April 24, 2015:
Apply Online at:
http://hsc.unm.edu/programs/diversity/index.shtml
Mail to:
UNM HSC Office for Diversity
MSCO8 4680
1 University of New Mexico
Albuquerque, NM 87131-0001
Deliver in person to:
UNM Health Science Center, UNM North Campus
Office for Diversity
Health Sciences and Services Building, Suite 102
Building #266, Campus Map
1
2015 ClinEd Application
Revised April 6, 2015
NEW MEXICO CLINICAL EDUCATION (ClinEd) PROGRM
PROGRAM DATES: JUNE 15, 2015 – JULY 24, 2015
APPLICATION CHECKLIST
APPLICANT NAME:
Complete application packets must include:
¨ Complete Student Application
¨ College Transcript(s): An unofficial transcript from all the schools that you have attended
¨ Resume
¨ MCAT test score report(s), if taken or proof of registration, if registered. (It is not a requirement to be
registered or have previously taken the MCAT.)
¨ Personal Statement: (The personal statement must be typed, double-spaced, 12-point font, Times New Roman, 1”
margins, and no more than 2 pages.) Please state your purpose in applying to this program. In this personal
statement we are seeking to capture not only a snapshot of where you are currently as a student but also where you
have been and where you see yourself in the future as a health professional. Relevant factors include but are not
limited to:
• Achievements you have accomplished in spite of educational, social, and economic challenges.
• What in your personal, work, or academic background has motivated your interest in a health career?
• What are your educational goals and how will they impact you, your family, and your community?
• What kind of educational experiences and skillset do you expect to gain this summer that will best assist you in
reaching your career goals and dreams?
¨ Two Completed Recommendation Forms
One form should be completed by someone who can evaluate your character and academic performance, such as a
professor, teacher, counselor, principal, mentor, employer, or volunteer supervisor. The second form can be from
someone of your choosing. Forms must be in a sealed envelope with the writer’s signature across the seal on the
back of the envelope.
¨ Required Interview
Office Use Only
Date Submitted:
Staff Initials:
2
2015 ClinEd Application
Revised April 6, 2015
NEW MEXICO CLINICAL EDUCATION PROGRAM
STUDENT APPLICATION
PERSONAL INFORMATION
Please make sure that the information given in this section is accurate and matches with any federal or state
issued document (ex. Social Security card, ITIN card).
1.
Name:
2.
Address:
Last
First
Middle
Street Address or P.O. Box Number
City or Town
County
State
3.
Phone:
4.
UNM Banner or Student ID:
5.
Gender:
□ Female □ Male
6.
U.S. Citizen:
□ Yes
7.
New Mexico Resident:
8.
Date of Birth:
10.
Do you consider yourself to be Hispanic/Latino(a)? □ Yes
□ No
In describing yourself, please select one or more of the following racial categories:
□ American Indian or Alaskan Native (Specify affiliation):
Zip Code
Email Address:
□ No
If no, can you provide a SSN or ITIN:
□ Yes
□ No
□ Yes
□ No
If no, state of residency:
9. Place of Birth:
□ Asian □ Black or African American □ Native Hawaiian/Pacific Islander
□ White □ Other (Please specify):
11.
What was your first language?
What is the primary language spoken at home?
EDUCATIONAL BACKGROUND
12.
Please list schools you are attending and/or have attended beginning with high school:
School Name
City and State
Dates of Attendance
Cumul. GPA
High School:
College:
College:
13.
Indicate your current year in college: □ Freshman
□ Sophomore
□ Junior
□ Senior
□ Graduate
Please indicate anticipated or actual college graduation date:
14.
Undergraduate Major/Minor:
Graduate Program:
15.
Overall GPA:
16.
Please list general prerequisite courses that you have taken (indicate course numbers):
General Biology:
General Chemistry:
General Physics:
Mathematics:
Organic Chemistry:
English:
17.
Have you taken the MCAT? □ Yes □ No If so, please list score(s) and date(s). (Attach copy of MCAT score
report.)
18.
If not, please list the date you intend to take it:
3
2015 ClinEd Application
Revised April 6, 2015
FAMILY BACKGROUND
Father/Guardian 1 (Required): Applicant lives with this parent/guardian: □ Yes
19.
Name:
20.
Address:
Last
□ No
First
Middle
Street Address or P.O. Box Number
City or Town
County
21.
Phone:
22.
Circle highest grade completed: 1
23.
Did your father/guardian attend college?
24.
Please check the highest level of degree obtained?
State
Email Address:
□ Associate Degree
25.
Occupation:
26.
Employer:
2
3
4
5
6
7
8
□ Yes
□ Bachelor’s Degree
9
10
11
Name:
28.
Address:
12
□ No
□ Master’s Degree
Mother/Guardian 2 (Required): Applicant lives with this parent/guardian: □ Yes
27.
Zip Code
Last
□ Doctoral Degree
□ Other
□ No
First
Middle
Street Address or P.O. Box Number
City or Town
County
29.
Phone:
30.
Circle highest grade completed: 1
31.
Did your mother/guardian attend college?
32.
Please check the highest level of degree obtained?
State
Zip Code
Email Address:
□ Associate Degree
2
3
4
5
□ Bachelor’s Degree
6
7
8
□ Yes
9
10
11
12
□ No
□ Master’s Degree
□ Doctoral Degree
33.
Occupation:
34.
Employer:
35.
How many siblings do you have?
36.
What is their range in age?
37.
Have any of them attended college?
□ Yes
□ No
If yes, how many?
38.
Have any attended graduate/professional school?
□ Yes
□ No
If yes, how many?
39.
Do you have any relatives in a health profession?
□ Yes
□ No
Which specific fields?
□ Other
FINANCIAL BACKGROUND
40.
I am currently financially supported by (check all that apply):
□ Self
□ Father
□ Mother
□ Other (state relationship to you):
41.
Total Annual Household Income:
42.
How many people live in your household (include yourself)?
43.
Number of children or dependents in your household (include ages):
4
2015 ClinEd Application
Revised April 6, 2015
ADDITIONAL INFORMATION
44.
Have you completed any other UNM HSC Office for Diversity programs (select all that apply)?
□ Dream Makers/Dream Makers +
□ HCA
45.
How did you find out about this program?
□ Office for Diversity
□ Friend/Parent
□ Instructor/Advisor
□ Flyer/brochure
□ Web Publications (websites, listserv)
□ Other (specify):
46.
Please list your health career interest(s):
47.
Please list any health related certifications or training you have received and date of completion:
(i.e. CPR, First Aid)
48.
Please list extra-curricular, volunteer, and/or community experiences:
(i.e. sports, school clubs, church activities, etc.)
49.
If applicable, please list any special needs or considerations you would like us to be aware of:
50.
What size T-Shirt would you like? □ S □ M □ L □ XL □ 2-XL
STATEMENT OF CERTIFICATION
I certify that all information given is true to the best of my knowledge. I understand that failure to disclose accurate
information is grounds for dismissal from or selection into the program. I agree to provide all necessary documentation. If
accepted into the ClinEd Program, I understand that my participation is a major educational privilege that can impact my
future, my family’s future, and the future of healthcare in New Mexico.
Signature of Applicant
Date
5
2015 ClinEd Application
Revised April 6, 2015
RECOMMENDATION FORM – PLEASE RETURN THIS WITH YOUR APPLICATION To the Applicant
Please fill in your name on the line below and give this information to the individual you have selected provide a
recommendation for you.
Applicant’s Name
To the recommending individual
The student named above is applying to the UNM Health Sciences Center, Office for Diversity’s New Mexico Clinical
Education Program (ClinEd). This program’s purpose is to provide experiences in rural clinical settings by placing students
in primary care facilities and community health centers throughout New Mexico. Students shadow clinicians and participate
in all aspects that the clinic and the community offer. This program seeks to identify students who demonstrate the following
characteristics:
• Financial need;
• Academic performance or promise;
• Interest in pursuing a health related career;
• Strength of character, evidence of leadership potential, and emotional maturity and stability;
• The potential to contribute to one’s community later in life.
Please provide your contact information below, in the case that the Office for Diversity staff has any pending questions or
concern.
Recommender Name:
Phone Number:
Email:
Relationship to Applicant:
To help in the selection of participants into the New Mexico Clinical Education Program, we ask that you please answer all
of the following questions. Please limit your answers to the allotted space provided.
ALL COMPLETED RECOMMENDATION FORMS MUST BE SUBMITTED IN A SEALED ENVELOPE TO THE
STUDENT PRIOR TO THE APPLICATION DEADLINE OF FRIDAY, APRIL 24, 2015.
How long and in what capacity have you known this applicant?
Please describe the applicant’s strengths?
Please comment on the applicant’s area(s) of development. What efforts has the applicant made to improve?
How has the applicant contributed above and beyond her/his expected responsibilities?
Please use the following space to include any additional comments. (Optional)
Please rate the applicant on the following categories:
Cannot
Recommend
Academic Performance
Leadership Qualities
Emotional Maturity
Reliability
Ability to interact with adults and peer
Professionalism
Resiliency (Ability to overcome barriers)
Below
Average
Average
Above
Average
Excellent
RECOMMENDATION FORM – PLEASE RETURN THIS WITH YOUR APPLICATION To the Applicant
Please fill in your name on the line below and give this information to the individual you have selected provide a
recommendation for you.
Applicant’s Name
To the recommending individual
The student named above is applying to the UNM Health Sciences Center, Office for Diversity’s New Mexico Clinical
Education Program (ClinEd). This program’s purpose is to provide experiences in rural clinical settings by placing students
in primary care facilities and community health centers throughout New Mexico. Students shadow clinicians and participate
in all aspects that the clinic and the community offer. This program seeks to identify students who demonstrate the following
characteristics:
• Financial need;
• Academic performance or promise;
• Interest in pursuing a health related career;
• Strength of character, evidence of leadership potential, and emotional maturity and stability;
• The potential to contribute to one’s community later in life.
Please provide your contact information below, in the case that the Office for Diversity staff has any pending questions or
concern.
Recommender Name:
Phone Number:
Email:
Relationship to Applicant:
To help in the selection of participants into the New Mexico Clinical Education Program, we ask that you please answer all
of the following questions. Please limit your answers to the allotted space provided.
ALL COMPLETED RECOMMENDATION FORMS MUST BE SUBMITTED IN A SEALED ENVELOPE TO THE
STUDENT PRIOR TO THE APPLICATION DEADLINE OF FRIDAY, APRIL 24, 2015.
How long and in what capacity have you known this applicant?
Please describe the applicant’s strengths?
Please comment on the applicant’s area(s) of development. What efforts has the applicant made to improve?
How has the applicant contributed above and beyond her/his expected responsibilities?
Please use the following space to include any additional comments. (Optional)
Please rate the applicant on the following categories:
Cannot
Recommend
Academic Performance
Leadership Qualities
Emotional Maturity
Reliability
Ability to interact with adults and peer
Professionalism
Resiliency (Ability to overcome barriers)
Below
Average
Average
Above
Average
Excellent