Northeast Regional Alliance MedPrep

IMPORTANT:


Note: Residents of New Jersey can only apply to the NJMS Program and Residents of New York (five boroughs of NYC, Long Island and Westchester) can only apply to the Columbia Program. Application Deadline: March 1st, 2012.
 HCOP UMDNJ - New Jersey Medical School
 HCOP Columbia University College of Physicians and Surgeons
 HCOP Mount Sinai School of Medicine
 

Program Eligibility:

Status: Freshman  Sophomore   Junior  Senior 
Educational Opportunity Fund: Yes  No  Not Applicable 
Educational Opportunity Program: Yes  No  Not Applicable 
Interested in Medicine: Yes  No  Unsure 
 

Personal Information:

Last Name:   First Name: 
Middle Name: 
Gender:    Male  Female
Date of Birth:  Ex: mm/dd/yyyy

Permanent Address:
Number, Street and Apt. No:
City:  State:  Zip Code: 

Preferred/Campus Mailing Address (if different from above):
City:  State:  Zip Code 

Home Telephone:   School Telephone: 
E-mail:   Cell Number: 
 

Racial Self - Description:

Ethnicity (please specify):
 Hispanic or Latino
 Not Hispanic or Latino
Race (please specify):
 American Indian or Alaska Native
 Asian (Not Underrepresented)
 Asian (Underrepresented)*
 Black or African American
 Native Hawaiian or Other Pacific Islander
 White
 More Than One Race
* Any Asian other than Chinese, Filipino, Japanese, Korean, Asian Indian or Thai.
 
Citizenship Status:
 U.S. Citizen   Permanent Resident
 

Parent or Guardian Information:

NOTE: Please check the box for which you are providing the information.
Name of: Mother or Guardian

Highest Level of Education:   Elementary    High School    Undergraduate  Graduate
Name of Institution: 
Country:   Occupation: 
Name of: Father or Guardian
Highest Level of Education:   Elementary    High School    Undergraduate  Graduate
Name of Institution: 
Country:   Occupation: 
Number of Dependents in Household: 
Ages of brothers:    Ages of sisters: 
Do you consider yourself economically disadvantaged?  Yes  No
Combined Household Income:
  Below $20,000   $20,000 - $40,000   $40,000 - $60,000
  $60,000 - $80,000   $80,000 - $100,000    Over $100,000
 

Education Background

Undergraduate Education: Please list all institutions attended. All official transcripts and letters of recommendations should be mailed to the appropriate site directly. Contact information for each site is provided at the end of this application. NOTE: Transcripts must be provided for all institutions attended.
 
Name of School: 
Street Address: 
City:  State:  Zip Code 
Date of Matriculation  Expected Graduation Date:  Major  
GPA 
 
Undergraduate Education:
 
Name of School: 
Street Address: 
City:  State:  Zip Code 
Date of Matriculation  Expected Graduation Date:  Major  
GPA 
 

Academic Enrichment / Internship

Have you participated in any Academic Enrichment / Internship?  Yes   No
(Please indicate in the space provided below)
Name of Program(s):
Program Director: 
Telephone & or Email address: 
Please specify when you participated in this program (ie. Summer of ...): 
Name of the Institution where the program was held:
 
Name of Program(s):
Program Director: 
Telephone & or Email address: 
Please specify when you participated in this program (ie. Summer of ...): 
Name of the Institution where the program was held:
 

Standardized Testing Information

If applicable, please provide the required information:
SAT Scores
Date(s)Critical ReadingMathematicsWritingTotal
ACT Scores
Date(s)Critical ReadingMathematicsWritingTotal
 

Please answer the following questions:

In the event of an emergency, person(s) to be contacted:
Name: Relationship: Telephone #: 
Name: Relationship: Telephone #: 
 
How did you hear about the Northeast Regional Alliance Health Careers Opportunity Program?
Web:    Mailing:   Academic Advisor:   Other:  
 

PERSONAL STATEMENT:

Please write two short essays, 500 word maximum for each, on the following topics. Please type your answers below.
 
1. Please describe which career you are most interested in and why?
 
2. How do you think that participation in the Northeast Regional Alliance HCOP will help you achieve your goal of attaining a career in medicine?
 
I hereby certify that the information that I have provided is true and accurate to the best of my knowledge. I understand that it is a competitive application process and acceptance into the program is at the discretion of the selection committee. I have read and accept this certification statement.
 
Student Signature (full name):   Date: 
Funding provided by the Northeast Regional Alliance Health Careers Opportunity Program through HRSA Bureau of Health Professions D18HP10627
 
                                                                        
Contact Information
Victor Marques
UMDNJ - New Jersey Medical School
Office of Special Programs
185 South Orange Avenue,
Medical Science Building, B-624
Newark, New Jersey 07101 		Nicole Spruill
Columbia University, College of Physicians & Surgeons
Office of Diversity
630 W 168th Street, Suite 3-401-Room 411
New York, NY 10032

Lloyd Sherman, EdD
Mount Sinai School of Medicine
Center for Multicultural & Community Affairs
1 Gustave L. Levy Place, Box 1035
New York, New York 10029