Health Sciences Scholar Institute (HSSI) 2017 Application Packet

Center of Excellence for Diversity in Medical Education Please scan and email, fax, or drop off application and all materials to: Health Sciences Scholar Institute – Mrs. Theresa Blanks Michigan State University College of Human Medicine 1355 Bogue St., B209 East Lansing, MI 48824 Fax: 517-432-1051 [email protected] Application Deadline: Friday, May 26, 2017 by 5:00 p.m.

Center of Excellence 2017 Health Sciences Scholar Institute (HSSI) Pre‐College Program PROGRAM DATES: July 10, 2017 ‐ August 4, 2017 APPLICATION DEADLINE: May 26, 2017

Do you have a STRONG interest in becoming a physician? The Health Sciences Scholar Institute (HSSI) is an intensive non‐residential program designed for students interested in the medical profession who meet the criteria below. The program meets Monday through Friday and will require daily attendance and participation at the assigned community site. The Institute will be offered in Flint, Grand Rapids and Lansing. The following criteria must be met by participants to apply:  Current 10th and 11th graders with a minimum 3.0 GPA (unofficial transcript is required)  A member of at least one of the following groups: African‐American, Hispanic/Latino, Native American, and/or underrepresented Asian (identifies as: Bangladeshi, Cambodian, Indonesian, Laotian, Taiwanese, Pakistani, Vietnamese groups) To request further information, please email Mrs. Theresa Blanks at [email protected] or call 517‐884‐1844.

Center of Excellence 2017 Health Sciences Scholar Institute (HSSI) Pre-College Program PROGRAM DATES: July 10 - August 4, 2017 APPLICATION DEADLINE: Friday, May 26, 2017 The Health Sciences Scholar Institute (HSSI) is an intensive non-residential program designed for students interested in the medical profession to ensure diversity and equality in medical education. The following criteria must be met by participants to apply for the pre-college program. Eligibility to apply: 1. Current 10th and 11th graders with a minimum 3.0 GPA (an unofficial transcript is required) 2. A member of at least one of the following groups: African-American, Hispanic/Latino, Native American, and/or underrepresented Asian (identifies as: Bangladeshi, Cambodian, Indonesian, Laotian, Taiwanese, Pakistani, Vietnamese groups) 3. Have a STRONG interest in becoming a physician (a M.D. specifically) The program meets Monday through Friday and will require daily attendance and participation at the assigned community site. The Institute will be offered in Flint, Grand Rapids, and Lansing. Programming for this four-week experience includes:        

Educational enrichment in the sciences at grade appropriate levels and preparatory support for college entry. For example: math, science, reading and writing SAT preparation Cultural Competency Training (age and grade appropriate) Training in community-based participatory research (age and grade appropriate) Exposure to Medicine in the Arts – including literature and other works which explore Underrepresented Minorities in Medicine Use science, math and medical humanities to tackle community health issues in their respective communities Exploring and examining real medical cases daily Completion of a health-related community project

Please submit the completed application packet – the form and the actual application - to Mrs. Theresa Blanks at [email protected] , fax (517) 432-1051 or send to Health Sciences Scholar Institute, Michigan State University College of Human Medicine, 1355 Bogue Street, B209, East Lansing, MI 48824 no later than 5:00 p.m. Friday, May 26, 2017

Center of Excellence 2017 Health Sciences Scholar Institute (HSSI) Application July 10 – August 4, 2017 New Application Returning Student Date: ___/____/____

Grade you will enter in September 2017:

Student Information: Name: Last

First

Middle

Mailing Address: City:

State:

Zip code:

County: Home Phone #: Date of Birth: Student Email Address:

Student Cell Phone #: Age: _____

Gender: Female

Male:

@

Parent/Guardian Name: Please check your self-description: African-American/Black Latino/Hispanic Native American Other

Please specify:

Underrepresented Asian (Bangladeshi, Cambodian, Indonesian, Laotian, Taiwanese, Pakistani, Vietnamese)

U.S. Citizen? Yes: No: {The program is open to U.S. Citizens or Permanent Resident who possess a social security number.} If not, are you a Permanent Resident? Yes: No: Please fax copy of documentation. (517) 432-1051

School Information: Current high school:

School District:

Cumulative GPA:

Must be at least a 3.0*

*Unofficial copy of your transcript must be included with completed application* Guidance Counselor: ACT: Score (if taken)

ACT: Future Test Date:

SAT: Score (if taken)

SAT: Future Test Date:

Please answer the following question: How likely are you to become a physician? Very Unlikely

Unlikely

Neutral

Please list current courses at the time of application:

Please list all planned courses for Fall 2017:

Likely

Very Likely

Please list all high school Math courses completed by grade in chronological order:

Please list all high school Science courses completed by grade in chronological order:

Please list all high school English/Writing courses in chronological order:

Please list all high school Social Studies courses in chronological order:

Parental Information: (fill out what applies to you) Mother’s full name: Mother’s daytime telephone: Email:

Mother’s cell phone: @

Father’s full name: Father’s daytime telephone: Email:

Father’s cell phone: @

Guardian’s full name: Guardian’s daytime telephone:

Guardian’s cell phone:

Email:

@

Please complete this section: Mother: Did not complete high school High School Diploma Trade School Certificates Associates Degree Bachelor’s Degree or higher Father: Did not complete high school High School Diploma Trade School Certificates Associates Degree Bachelor’s Degree or higher Guardian: Did not complete high school High School Diploma Trade School Certificates Associates Degree Bachelor’s Degree or higher

Essay Question 1: Please type your response below: (Response must be a minimum of 250 words) Why do you want to become a physician? Please include any experiences such as shadowing or other things that have influenced your decision.

Essay Question 2: Please type your response below: (Response must be a minimum of 250 words) For new scholars: How would participation in the Health Sciences Scholar Institute (HSSI) support your interest and goal of becoming a physician? Please be specific.

Please type your response below: (Response must be a minimum of 250 words) For returning scholars: How did your participation in Health Sciences Scholar Institute (HSSI) influence your journey of becoming a physician? Please be specific.

Please submit the completed form to Mrs. Theresa Blanks at [email protected] by fax (517) 432-1051 or send to Health Sciences Scholar Institute, Michigan State University College of Human Medicine, 1355 Bogue Street, Room B-209, East Lansing, MI 48824 no later than 5:00 p.m. Friday, May 26, 2017. This is a non-residential program.

T:\coe\HSSI 2017\2017 Health Science Scholar Institute app.docx

Center of Excellence Health Sciences Scholar Institute (HSSI) 2017 Recommendation Form (To be completed by a current teacher, counselor, school administrator or community leader)

Please type or print legibly Michigan State University College of Human Medicine is pleased to offer an exciting summer opportunity to current 10th and 11th grade high school students with a minimum GPA of 3.0 who have a strong interest in becoming a physician. The dates are July 10–August 4, 2017. We are looking for competitive, highly motivated, and college focused students who are underrepresented in the field of medicine. If you know of an outstanding student to recommend who meets the criteria, we are asking for your candid feedback regarding the student’s performance in school and level of readiness for the Health Sciences Scholar Institute. Student Name: Completed by: Email: Title:

Phone:

How long have you known this student?

0-1 years

2-5 years

6 or more

Please place a check mark to indicate your evaluation of the student named above based on the student’s performance for each of the criteria listed below. Below Criteria Outstanding Good Average Average Interest in becoming a physician Completion of assignments on time Ability to work independently Ability to work with others Self-motivated to excel Personal conduct/behavior in classroom Problem solving & critical thinking skills Self-discipline as a learner Class attendance Class participation Additional comments: Please place a check mark in the box to indicate your overall evaluation of this student’s interest and readiness for a Health Profession enrichment program. Outstanding

Good

Signature *

Average

Below Average

Date

Please submit the completed for to Mrs. Theresa Blanks at [email protected], fax to 517-432-1051 or send to Health Sciences Scholar Institute, Michigan State University College of Human Medicine, 1355 Bogue Street, Room B-209, East Lansing, MI 48824 no later than 5:00 p.m., Friday, May 26, 2017. * Your email will serve as your electronic signature.

Center of Excellence 2017 Health Sciences Scholar Institute (HSSI) July 10 – August 4, 2017 Application Check List Use this checklist below to ensure that you have submitted all required items with your application packet. Please check off the items that are included when submitting your application packet to Mrs. Theresa Blanks.

Completed Application

Completed Essay Question Answers

Recommendation Form

Transcript Please note: INCOMPLETE APPLICATIONS WILLNOT BE REVIEWED. Applications will be reviewed for acceptance only after ALL of the required information and document have been received. Space for the program is limited, so you are strongly encouraged to submit your application prior to the due date. We will start the selection process upon receipt of your application. The program will review applications on a rolling basis. The application deadline is May 27, 2017. It is our goal to notify all students no later than June 23, 2017. Please submit the completed form to Mrs. Theresa Blanks at [email protected], fax (517) 432-1051 or send to Health Sciences Scholar Institute, Michigan State University College of Human Medicine, 1355 Bogue Street, B-209, East Lansing, MI 48824 no later than 5:00 p.m. Friday, May 27, 2016. Office Use Only:

CAMPUS: File Folder

Flint

Grand Rapids E-Folder

Lansing