Pre-Med Summer Scholar Program

Application Instructions

Current high school sophomores and junior students between age 16 and 18 years old are eligible to

apply

Due to complexities, only students attending high school within the United States will be considered

*If you have Adobe Acrobat, you may type-in your responses in the required fields and then print-out.

• Cover Sheet

o Please fill out the cover sheet in BLUE or BLACK ink only

• Application + Essays

o Please fill out the application in BLUE or BLACK ink only

o Print legibly and neatly

o You may type your essay and add the separate page to the application, if necessary

o Applicant’s signature and parent/guardian’s consent and signature is required

• CV/Resume (limit to 1 page)

o Include school clubs, extracirricular activites, volunteer experience and awards and certificates

• Transcript (Minimum GPA 3.3)o Please attach a copy of your transcript with your most recent CUMULATIVE GPA

o The UCLA Health Pre-Med Summer Scholar Team will NOT calculate your GPA. If there is no apparent cumulative GPA visible, your application will be considered incomplete.

o If you do not have Fall 2019 grades available yet, cumulative GPA from May/June 2019

(Summer) is acceptable. Any GPA earlier than Summer 2019 will NOT be accepted.

• Program Requirement Acknowledgement

o Please sign and note: Certificate is available only upon completion of the program.

• Confidential Recommendations

o 2 Confidential Recommendations from your school are required (no relatives, employers, or volunteer supervisors should be providing your recommendation)

o Please provide your evaluators with the Confidential Recommendation form and an envelope (a standard #10, 4 1/8”H x 9 ½”W envelope will suffice). Please make sure your full name and birthday on the front of the envelope.

o Your evaluator has been instructed to place and seal your completed recommendation in the provided envelope

o Please add your sealed recommendations to your application packet

_________________________________________________________________________________________

Final Checklist Please organize in this order. Do NOT staple.

____Cover Sheet

____Application + Essays

____CV/Resume

____Transcript (Cumulative GPA)

____Program Requirement Acknowledgement

____2 Confidential Recommendations (sealed)

______________________________________________________________________________

PLEASE MAIL COMPLETE APPLICATION PACKET TO:

Ronald Reagan UCLA Medical Center – Volunteer Services

ATTN: Pre-Med Summer Scholar Program

757 Westwood Plaza, ste. B-791

Los Angeles, CA 90095

Deadline: Postmarked by Friday, February 21, 2020

NO EXCEPTIONS.

Pre-Med Summer Scholar Program

Cover Sheet

Name:

Birthday:

Age:

School:

Grade Level:

Email:

Parent’s Email:

Shirt Size:

PRE-MED SUMMER SCHOLAR APPLICATION

Ronald Reagan UCLA

757 Westwood Plaza, Suite B791 Deadline: February 21, 2020

Los Angeles, CA 90095

(310) 267-8180

UCLA Health is committed to a policy of equal opportunity for all volunteer applicants. The University of California

prohibits discrimination against or harassment of any person recruited by or seeking recruitment with the

University on the basis of race, color, national origin, religion, sex, gender identity, pregnancy, physical or mental

disability, medical condition (cancer-related or genetic characteristics), ancestry, marital status, age, sexual

orientation, citizenship, or service in the uniformed services.

Date:

Last Name: First Name: Middle:

Birthdate: Month: Day: Year: Age:

Street Address: Apt#:

City: State: Zip Code:

Phone # (with area code): Cell Phone # (with area code):

Email Address:

Parent’s Name & Email Address:

Parent’s Phone # (with area code):

Emergency Contact: Emergency Phone#:

High School Name:

Cumulative GPA (copy of transcript required):

What year are you currently in? (click one) Sophomore Junior

How did you hear about our program?

If you have any relatives working within UCLA Health, please provide their information:

Name: Relationship: Department:

Name: Relationship: Department:

Please provide the names of two (2) teachers or school counselors who can provide a recommendation on your behalf:

Name of teacher/counselor Subject E-Mail Address

Essay #1: Write about yourself and your reasons for participating in the Pre-Med Summer Scholar Program (limit 500

words). Topics may include but are not limited to: a personal story or challenging experience, any of your special skills

and qualities that would make you a standout candidate for the Pre-Med Summer Scholar program.

Essay #2: Pinpoint a challenge in health care. Have you encountered this issue in your own life? What was the outcome?

What could be improved? How would you resolve the problem? (limit 500 words).

List any previous volunteer experiences you may have had:

VOLUNTEER AGREEMENT AND CERTIFICATION OF INFORMATION

Believing that UCLA Health has need of my services as a volunteer, I agree:

1. To hold as absolutely confidential all information that I may obtain directly or indirectly concerning patients,

families, physicians, or personnel. I agree that I will not seek confidential information in regard to a patient.

2. That if I accept a volunteer position, I will have a duty to be familiar with UCLA Health’s rules, standards, and

policies as they now exist or as they may be modified, added to, or abolished in the future. I agree to comply with

following these rules, standards, and policies.

3. To wear the designated volunteer uniform and ID at all times while volunteering in the medical facility.

4. I certify that the answers given by me to the foregoing questions are true and without omissions. I authorize

UCLA Health to investigate and/or verify any information relevant to my suitability as a volunteer.

5. To commit to my given program schedule and to limit my absence(s) to no more than once (1) throughout the

entire program. I understand that this program is only available in the summer for a period of one (1) week and

that failure to turn in all my documents and paperwork will not qualify me for a volunteer position.

6. That if I do not complete the requirements of the program, including all volunteer shifts, I will be not be eligible

for program certificate or hours verification.

Applicant signature: __________________________________________Date: _______________________

PARENT CONSENT REQUIRED

I agree that the information contained in this application is correct. I am aware of the various tasks that my daughter/son

will be required to perform. My daughter/son has my permission to serve as a volunteer at UCLA Health. To protect the

health of my daughter/son and out patients, I give permission for my daughter/son to receive all necessary tests and/or

vaccinations, including TB tests, as part of her/his health clearance for volunteer work within UCLA Health. I understand

UCLA Health is not responsible for transportation and parking fees. I agree to give permission to have my son/daughter’s

picture taken and published and acknowledge that this image may be used in any UCLA Health Marketing.

I understand the responsibility my son/daughter is taking on and will encourage his/her commitment and regular attendance

as promised.

I understand this application is not complete without my signature and ensure the signature below is my own.

Parent signature: ______________________________________________Date: _______________________

Pre-Med Summer Scholar Program

Program Requirement Acknowledgement

You must attend every day of the session to receive a program certificate of completion/recognition. Due to the expected high volume of applicants, it is requested that you do not submit an application unless you are available to attend all program dates of your selected session.

2020 Program Dates Ronald Reagan UCLA Medical Center

757 Westwood Blvd. Los Angeles CA 90095

Date Time

May 2nd (Saturday) Check-In Day 8am-12pm

I can commit to: Session 1: Monday, June 8th (9AM-4PM) – Saturday, June 13th (9AM-12PM) Session 2: Monday, June 15th (9AM-4PM) – Saturday, June 20th (9AM-12PM) Session 3: Monday, July 6th (9AM-4PM) – Saturday, July 11th (9AM-12PM) Open to any session

I understand:

1) There is a $1000 fee associated with participating in the UCLA Health Pre-Med Summer ScholarProgram. A non-refundable payment of $1000 (cash or check) is due on Check-In Day May 2nd, 2020.

2) Check-In Day requires my attendance and I plan to be present on Saturday, May 2nd, 2020.

3) Once session is chosen and assigned, I cannot request to transfer in to an alternate session.

I certify that I have read the above information and agree to the program requirements. I acknowledge that if I do not complete the requirements of the program or attend all dates listed above, I will not be eligible for a refund or receive a program certificate.

_______________________________ ____________________________ Student Signature Student Printed Name

_______________________________ ____________________________ Parent Signature Parent Printed Name

Pre-Med Summer Scholar Program

Confidential Recommendation

Dear Evaluator,

Your student has chosen you to fill out a recommendation in hope to participate in UCLA Health’s Pre-Med Summer Scholar Program. Please take time to provide your true and honest evaluation concerning the student.

The applicant has been instructed to give you this evaluation to complete. To maintain confidentiality, please place this evaluation in the envelope your student has provided you. Please seal the envelope, and sign your name across the seal to ensure the envelope has not been tampered with. There is no need to create a separate letter of recommendation. Application for the program, including your confidential recommendation, is due no later than FRIDAY, FEBRUARY 21, 2020.

Kind regards,

UCLA Health Pre-Med Summer Scholar Program Team

Student: _________________________________ School: _______________________________

Evaluator: ________________________________ Subject: ______________________________

Evaluator Email: ___________________________ Evaluator Phone: ______________________

I confirm that I am the actual evaluator of this recommendation and acknowledge that I may be contacted to verify the authenticity of the evaluation. Evaluator signature: ________________________________________

1) How long have you known the applicant?

2) How would you rate the applicant? Excellent Good Fair Poor

Attendance

Positive attitude

Comes to class prepared

Teamwork skills

Initiative

Respectful to others

Willingness to assist

Ability to follow direction

Ability to take criticism

Ability to admit fault or responsibility

3) Do you have any reservations concerning the applicant?

4) Do you have any additional information or comments you feel would assist the UCLA Health Pre-Med

Summer Scholar Team in evaluating the applicant? Please limit to 1-3 sentences.

Pre-Med Summer Scholar Program

Confidential Recommendation

Dear Evaluator,

Your student has chosen you to fill out a recommendation in hope to participate in UCLA Health’s Pre-Med Summer Scholar Program. Please take time to provide your true and honest evaluation concerning the student.

The applicant has been instructed to give you this evaluation to complete. To maintain confidentiality, please place this evaluation in the envelope your student has provided you. Please seal the envelope, and sign your name across the seal to ensure the envelope has not been tampered with. There is no need to create a separate letter of recommendation. Application for the program, including your confidential recommendation, is due no later than FRIDAY, FEBRUARY 21, 2020.

Kind regards,

UCLA Health Pre-Med Summer Scholar Program Team

Student: _________________________________ School: _______________________________

Evaluator: ________________________________ Subject: ______________________________

Evaluator Email: ___________________________ Evaluator Phone: ______________________

I confirm that I am the actual evaluator of this recommendation and acknowledge that I may be contacted to verify the authenticity of the evaluation. Evaluator signature: ________________________________________

1) How long have you known the applicant?

2) How would you rate the applicant? Excellent Good Fair Poor

Attendance

Positive attitude

Comes to class prepared

Teamwork skills

Initiative

Respectful to others

Willingness to assist

Ability to follow direction

Ability to take criticism

Ability to admit fault or responsibility

3) Do you have any reservations concerning the applicant?

4) Do you have any additional information or comments you feel would assist the UCLA Health Pre-Med

Summer Scholar Team in evaluating the applicant? Please limit to 1-3 sentences.