June 14 to July 21, 2010
 
Application
 
Directions: Please complete and submit the application by March 1, 2010.
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
     
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 if you qualify for the program based on economic disadvantage. Please check and complete one category below, using 2008 or most recent Federal Tax data. All information is kept confidential.
     
  A. A copy of parents' 2008 Federal Tax Form 1040 is being mailed (pages 1 and 2 only)
  B. Parents not required to file 2008 Tax Form because
  C. 2008 Federal Tax Form not yet filed.
          (Please mail 2007 Form 1040, pages 1 and 2 only.)
     
12. Do you have medical/health insurance?
     
     
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?
     
     
  If "Yes", please indicate which school(s):
     
     
5. Have you taken the MCAT examination?
     
    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, 2009 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
     
1. How do you hope the Summer Scholars Program will help you achieve your academic 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, by March 1, 2009 to

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

For more information, please call 800-345-1560

 
   

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  Ohio University
College of Osteopathic Medicine
102 Grosvenor Hall, Athens, Ohio 45701
 1-800-345-1560
Last updated: 09/10/2009