June 3 to July 10, 2013
 
Application
 
Directions: Please complete and submit the application by March 1.
Personal Information
     
1. First Name:  
  Middle Name:  
  Last Name:  
     
2. E-mail Address:  
     
3. Current Mailing Address:
   
Street:  
City:   
County:  
State:  
Zip:  
     
  Telephone Number at Current Address:
      (include area code)
     
  Cell Phone:   (include area code)
     
4. Permanent Address (if different than above):
   
Street:  
City:  
County:  
State:  
Zip:  
     
  Telephone Number at Permanent Address:
      (include area code)
     
5. Date of Birth:   (mm/dd/yyyy)
  Age:  
  Gender:  
     
6. Place of Birth:
City:  
County:  
State:  
Zip:  
Country:  
 (if not U.S.A.)
     
7. Are you a U.S. citizen?  
    If Naturalized, mail documentation to the address below

If "No", are you a permanent resident?  
    If "Yes", mail documentation to the address below

     Have you registered for selective service? 

     
8. Status Identified to Meet Criteria:
    Educationally Disadvantaged
Economically Disadvantaged
Underrepresented Minority
     
9. How do you
describe yourself? 		 
    If "other", please specify:
 
     
    If Asian/Pacific Islander, please indicate family's country of origin:
 
     
10. Father:  
   
Full Name:  
Occupation:  
Highest Level of Education:  
     
  Mother:  
   
Full Name:  
Occupation:  
Highest Level of Education:  
     
11. Your parents' income information is necessary only if you qualify for the program solely based on economic disadvantage. Please check and complete one category below, using 2012 or most recent Federal Tax data. All information is kept confidential.
     
  A. A copy of parents' 2012 Federal Tax Form 1040 is being mailed (pages 1 and 2 only)
  B. Parents not required to file 2011 Tax Form because
  C. 2012 Federal Tax Form not yet filed.
          (Please mail 2011 Form 1040, pages 1 and 2 only.)
     
12. Do you have medical/health insurance?
     
  (Not having medical insurance does not exclude you from participation; however, all medical expenses incurred while a participant are the responsibility of said participant.)
     
13. How did you find out about the Summer Scholars program?
     
If "other", please specify:
     
     
Your Education
     
1. List in chronological order all schools, colleges and universities attended, or currently attending, whether or not a degree was granted:
   
 
Institution & Location:  
City:  
State:  
Major Field:  
Dates Attended:  
Degree:  
   
 
Institution & Location:  
City:  
State:  
Major Field:  
Dates Attended:  
Degree:  
   
 
Institution & Location:  
City:  
State:  
Major Field:  
Dates Attended:  
Degree:  
   
 
Institution & Location:  
City:  
State:  
Major Field:  
Dates Attended:  
Degree:  
     
2. Current Academic Status:
     
     
3. Expected Completion Date of Current Program: 
      (mm/yyyy)
     
  Degree Expected:  
     
4. Have you applied to medical school or another health profession school for admission within the past two years?
     
     
  If "Yes", please indicate which school(s):
     
     
5. Have you taken the MCAT examination?
     
    If yes, when? (mm/yyyy)
  What were your scores?
Verbal Reasoning:  
Physical Sciences:  
Biological Sciences:  
Writing Sample:  
  If "No", when do plan to take the MCAT?
      (mm/yyyy)
 (must be taken no later than May, 2013 to be eligible for interview)
     
6. What academic honors, prizes or scholarships have you received in high school or college?
     
     
7. Have you attended other college-level premedical summer programs?
     
   
  If "Yes", please indicate which program(s):
     
     
8. Have you participated in a Post-Baccalaureate program?
     
  If "Yes", where?  
     
     
Activities
     
1. List your principal extracurricular and community activities (excluding jobs) during high school and college:
   
 
Activity Dates of Participation Position Held
     
2. List current and previous jobs held in the past three years:
     
 
Position and Employer Dates of Employment Hours/Week
     
     
References
     
  These should be faculty persons whom you will request to submit our
Confidential Evaluation form.
     
1. Name:  
  Address:
Street:  
City:  
State:  
Zip:  
  Telephone:   (include area code)
  E-Mail:  
     
2. Name:  
  Address:
Street:  
City:  
State:  
Zip:  
  Telephone:   (include area code)
  E-Mail:  
     
     
Summer Scholars Program Essays (not to exceed 750 words each)
     
1. How do you hope the Summer Scholars Program will help you achieve your academic and professional goals?

 
     
2. What personal qualities or experiences do you have that would make you a good osteopathic physician?

 
     

Please mail all supporting documentation, including confidential evaluations, transcripts and tax forms (if applicable), by March 1, 2013 to

Ohio University Heritage College of Osteopathic Medicine
Admissions Office - Summer Scholars
102 Grosvenor Hall
Athens, Ohio 45701

For more information, please call 800-345-1560

 
   

ABOUT SUMMER SCHOLARS
ELIGIBILITY
PREMED ADVISORS PAGE
APPLICATION FILES
APPLICATION PDF
EVALUATION PDF
INFORMATION PDF
CONTACT US
FAQ
HOME		  
 
  EDUCATION | RESEARCH | COMMUNITY | DIVERSITY | HOME
   
     
  Ohio University
Heritage College of Osteopathic Medicine
102 Grosvenor Hall, Athens, Ohio 45701
 1-800-345-1560
Last updated: 10/02/2012