U-DOC 2010 Summer Program Application

U-DOC 2010 High School Summer Program Application

Required questions marked with *

(but be sure to complete the rest, too)

Deadline and other important information will
appear when you submit your application.


Question 1. What is your last name?
		*

Question 2. What is your first name?
		*

Question 3. Enter your best contact phone number
		*

Question 4. Enter your best contact email address
		*

Question 5. Enter your street address
		*

Question 6. Enter your city
		*

Question 7. Enter your state
		*

Question 8. Enter your zip code
		*

Question 9. Enter your county
		*

Question 10. Enter your gender
		*

Question 11. Enter your birthdate
		*

Question 12. Enter your birthplace
		*

Question 13. What is your age?
		*

Question 14. What is your Social Security Number (###-##-####)?
		*

Question 15. Are you a US permanent resident? (documentation required)
		*

Question 16. How do you describe yourself? (for federal reporting purposes only)
		* Specify Other (if any)

Question 17. How many brothers and sisters do you have and how old are they?
		*

Question 18. Enter the name of the high school you are currently attending.
		*

Question 19. What city is your high school located?
		*

Question 20. What grade are you currently in?
		*

Question 21. Do you speak any languages other than English fluently? (Please specify.)
		*

Question 22. List the titles and grades received for science and math courses taken in high school.
		*

Question 23. Have you attended other pre-college summer programs?
		*

Question 24. If yes, which one(s) and when?


Question 25. List your top three career choices.
		*

Question 26. List extracurricular and sports activities you have been involved in while attending high school.
		*

Question 27. List any honors you have received while attending high school.
		*

Question 28. List jobs (paying or volunteer) that you held during high school, noting dates and approximate hours per week. (Babysitting and yardwork may be included)
		*

Question 29. How did you find out about U-DOC?
		*

We are interested in why you are seeking a health career and how an experience such as the U-DOC summer program can be of benefit to you. Please provide detailed answers for the following questions:

Question 30. Which health profession do you want to pursue? What is it about your life experiences, talents, personality that make this a good career choice? (150-250 words)


Question 31. Describe a health problem you've observed in your community. What are some strategies that could be used to combat this problem? (150-250 words)


Question 32. Choose one person you've known who has had a large impact on how you live your life. Describe your experience with that person and how it influenced you. (150-250 words)


Question 33. The U-DOC Summer Program is intended for students who are somehow disadvantaged. Describe, if any, what barriers or circumstances you face that would keep you from attending college or completing a college degree. (150-250 words)


Family Background: These questions are meant to be completed by Parent or Guardian.

Question 34. Parents marital status


Question 35. Father Last Name


Question 36. Father First Name


Question 37. Father Date of Birth


Question 38. Father Occupation


Question 39. Father Education, indicate level completed.


Question 40. Mother Last Name


Question 41. Mother First Name


Question 42. Mother Date of Birth


Question 43. Mother Occupation


Question 44. Mother Education, indicate level completed.


Question 45. Guardian Last Name


Question 46. Guardian First Name


Question 47. Guardian Date of Birth


Question 48. Guardian Occupation


Question 49. Guardian Education, indicate level completed.


Question 50. Have you or your spouse ever worked in a health care field?


Question 51. How many people currently reside in the family household, indicate numbers of adults and children.


Question 52. Have any of your children ever gone to college or vocational school? If yes, how many years?


Question 53. How likely is it for your child who is applying to UDOC to attend college?


Question 54. Are there any factors that would prevent your children from attending college or vocational school?


Question 55. Is your child eligible for the National Free/Reduced Price Lunch program?


Question 56. Total annual household income (including ADC, child support, alimony, etc)


Question 57. What is your family size?


Question 58. What is your health insurance and type of coverage?


IMPORTANT: PARTICIPATION IN THE U-DOC SUMMER PROGRAM INVOLVES MANY HOURS OF COURSEWORK, SEMINARS AND THE MENTORING EXPERIENCE. OUTSIDE JOBS, SUMMER SCHOOL OR SUMMER CAMP IS NOT RECOMMENDED. Student misconduct may result in removal from the U-DOC program.

This program is sponsored in part by grants provided by the Division of Disadvantaged Assistance, Bureau of Health Professions, Health Services Resource Administration of the Department of Health and Human Services.

By clicking the "submit" button on this application I CERTIFY THAT I FULLY UNDERSTAND THE ABOVE GUIDELINES AND THAT THE INFORMATION GIVEN IN THIS APPLICATION IS TRUE AND CORRECT.

Note: You must press the submit button and receive our thank you acknowledgment message in order to confirm that your application has been successfully submitted. If not then the application probably was not recieved, and you will need to re-submit. If there's any question you can email us to check on your application.