Premedical (TPP) Scholars Program - media.bcm.edu · Native American, Alaska Native, Eskimo, or Aleut Native Hawaiian or Other Pacific Islanders (Person Having Origins in Any of the

1/3/2019 BCM - COE Transformed Post-Baccalaureate Premedical Scholars Program Application

https://form.jotform.com/83446198703161 1/13

BCM Transformed Post-BaccalaureatePremedical (TPP) Scholars Program

Baylor College of Medicine Center of Excellence in Health Equity, Training and Research

One Baylor Plaza, MS: BCM411 Houston, TX 77030

Deadline to Apply: March 15

Complete the online application below and submit all supporting materials no later than5 p.m., March 15. Applicants are also responsible for making sure dean's certificationletter and letters of support are requested and received in time to include them withyour application package.

NOTE: This application is specifically for consideration into the Center of Excellence inHealth Equity, Training and Research Scholars Program. It is not intended to be anapplication for any other Baylor College of Medicine program, including admission to adegree granting program offered at Baylor.

NAME *

First Name

Middle Name

Last Name

Suffix

DATE OF BIRTH *

Month

Day

Year



CURRENT ADDRESS *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Please Select

Country

PERMANENT ADDRESS *

Street Address

Street Address Line 2


Postal / Zip Code

Please Select

Country

PRIMARY PHONE NUMBER *

-Area Code

Phone Number

MOBILE/CELL PHONE *

-Area Code

Phone Number

PRIMARY EMAIL ADDRESS *

ex: [email protected]

GENDER *

Male Female Non-Binary/Third

Gender Prefer Not to Say

Other



ARE YOU OF HISPANIC, LATINO, OR OF SPANISH ORIGIN? (ETHNICITY) *

Yes No

RACE *

Black or African American Native American, Alaska Native, Eskimo, or Aleut Native Hawaiian or Other Pacific Islanders (Person Having Origins in Any of the

Original Peoples of Hawaii, Guam, Tonga, Samoa, Fiji, The Marshalls or OtherPacific Islands)

White Asian

Other

NOTE: Per the conditions of the Health Resources and Services AdministrationCenter of Excellence grant program (COE) grant program, applicants must befrom one of the following underrepresented minority populations: Blacks orAfrican-Americans, Native Americans, Alaska Natives, Eskimos, Aleuts, NativeHawaiians or Other Pacific Islanders, or Hispanics or Latinos.

VETERAN STATUS *

Active Duty Military Reservist Veteran - Retired Veteran - Prior Service Not a Veteran

DO YOU COME FROM A DISADVANTAGED BACKGROUND? *

Yes No

NOTE: Disadvantaged background, as defined by the Health Resources andServices Administration, refers to a citizen, national, or a lawful permanentresident of the United States, the Commonwealths of Puerto Rico or the MarianasIslands, the U.S. Virgin Islands, Guam, American Samoa, the Trust Territory of thePacific Islands, the Republic of Palau, the Republic of the Marshall Islands, or theFederated State of Micronesia who:

1. Comes from an environment that has inhibited them from obtaining theknowledge, skills, and abilities required to enroll in and graduate from a healthprofessions or nursing school (Environmentally Disadvantaged); AND/OR 2. Comes from a family with an annual income below a level based on low-incomethresholds established by the U.S. Census Bureau, adjusted annually for changesin the Consumer Price Index (Economically Disadvantaged). The Secretary

https://bhw.hrsa.gov/fundingopportunities/?id=fabd901d-f6b1-45eb-913b-d491c1e6a747



defines a ‘‘low income family’’ for various health professions and nursing programsincluded in Titles III, VII and VIII of the Public Health Service Act as having anannual income that does not exceed 200 percent of the Department’s povertyguidelines. A family is a group of two or more individuals.

DO YOU COME FROM A RURAL RESIDENTIAL BACKGROUND?

Yes No

NOTE: Rural Residential Background, as defined by the Health Resources andServices Administration, is/are geographical area/s where an individual hasestablished residence that is not part of a Metropolitan Statistical Area (MSA). Todetermine whether a geographical area is considered rural, go to HRSA's Office ofRural Health Policy.

COUNTRY OF BIRTH *

COUNTRY OF CITIZENSHIP *

ARE YOU A U.S. CITIZEN, NON-CITIZEN U.S. NATIONAL, OR PERMANENTRESIDENT? *

Yes No

WHAT DO YOU CONSIDER YOUR PRIMARY SPOKEN LANGUAGE? *

ARE YOU BILINGUAL OR MULTILINGUAL? *

Yes No

ARE YOU A MEMBER OF THE FIRST GENERATION IN YOUR FAMILY TOATTEND/GRADUATE FROM AN UNDERGRADUATE DEGREE PROGRAM? *

Yes No

ARE YOU A MEMBER OF THE FIRST GENERATION IN YOUR FAMILY TOATTEND/GRADUATE FROM A GRADUATE OR POST-BACCALAUREATEPROFESSIONAL DEGREE PROGRAM? *

Yes No

http://datawarehouse.hrsa.gov/RuralAdvisor/RuralHealthAdvisor.aspx



Academic Information

ARE YOU A PARENT OR GUARDIAN OF DEPENDENT CHILDREN? *

Yes No

UNIVERSITY/COLLEGE (MOST RECENT) *

CITY, STATE * GRADUATED? *

HOURS COMPLETED *

ex: 23

DEGREE PROGRAM *

(e.g., Bachelor of Science)

MAJOR *

(e.g., Biology)

CUMULATIVE GPA *

ex: 3.4

BCPM GPA *

ex: 3.34Biology-Chemistry-Physics-Math Courses

LIST ANY RELEVANT SCHOLARSHIPS, AWARDS, AND HONORS (INCHRONOLOGICAL ORDER) *

PREVIOUS UNIVERSITY/COLLEGE 1 CITY, STATE



GRADUATED?

HOURS COMPLETED

ex: 23

DEGREE PROGRAM

(e.g., Bachelor of Science)

MAJOR

(e.g., Biology)

CUMULATIVE GPA

ex: 3.5

BCPM GPA

ex: 3.79Biology-Chemistry-Physics-Math Courses

TOTAL SCORE ON MOST RECENT SAT/ACT *

ex: 23

HAVE YOU APPLIED AND NOT BEEN ACCEPTED INTO TEXAS JOINTADMISSION MEDICAL PROGRAM (JAMP)? *

Yes No

PLEASE PROVIDE CONTACT INFORMATION FOR THE ACADEMIC DEAN ORPRE-HEALTH/PRE-MEDICAL/JAMP ADVISOR RECOMMENDING YOU FORTHIS PROGRAM:

NAME *

First Name

Last Name

TITLE *

DEPARTMENT *

COLLEGE/UNIVERSITY *



PHONE NUMBER *

-Area Code

Phone Number

EMAIL ADDRESS *

[email protected]

HAVE YOU TAKEN THE MCAT? *

Yes No

MCAT TEST DATE

mm-dd-yyyy Date

MCAT SCORE

ex: 23(e.g., 499)

HAVE YOU TAKEN THE GRE? *

Yes No

GRE TEST DATE:

mm-dd-yyyy Date

GRE SCORE

(e.g., V=550, Q=750, W=600)

Work History & Experience

ANTICIPATED APPLICATION DATE TO MEDICAL SCHOOL: *

Provide the Month and Year (e.g., May 2020)

HAVE YOU EVER BEEN EMPLOYED BY BAYLOR COLLEGE OF MEDICINE? *

Yes No

IF YES, LIST YOUR SUPERVISOR/MENTOR'S NAME

PERSONAL EMPLOYMENT HISTORY *



References

Please list any jobs you have held: (Format: Place of Employment, Title, Dates of Employment,Number of Hours Per Week)

CO-CURRICULAR INVOLVEMENT *

Please list any community service opportunities and student groups, including honor societies,you have participated in: (Format: Name of Project or Student Group, Organization or UniversityAffiliation, Role/Position, Dates of Involvement)

RESEARCH TRAINING/EXPERIENCE *

Please describe your research experience and/or the experience you hope to gain. If you havepublished any abstracts or papers that will be helpful in evaluation of your application, please listyour publications. (Format: yyyy - Title, Journal or Conference)

HEALTH EQUITY/SOCIAL JUSTICE EXPERIENCE *

Please describe your experience with health equity and/or social justice issues and/or theexperience you hope to gain.

NOTE: At least (2) letters of recommendation are required. At least one lettermust be from a faculty member at your school, preferably yourprehealth/premedical advisor. The other(s) can be from academic orprofessional sources (letters from friends or relatives will not be accepted).



Each of your references will need to complete the online evaluation form(https://www.jotform.com/build/83466138300150) by the March 15 deadline.

You will receive an email notification once a letter has been received on yourbehalf. Keep in mind you will not have access to the letters. Please convey theabove requirements to your referees before submitting your completedapplication.

REFERENCE #1 (FACULTY MEMBER) *

First Name

Last Name

TITLE *

DEPARTMENT *


ADDRESS *

Street Address


Postal / Zip Code

TELEPHONE NUMBER *

-Area Code

Phone Number

EMAIL ADDRESS *

[email protected]

REFERENCE #2 *

First Name

Last Name

TITLE *

DEPARTMENT *

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ADDRESS *

Street Address


Postal / Zip Code

TELEPHONE NUMBER *

-Area Code

Phone Number

EMAIL ADDRESS *

[email protected]

OPTIONAL: REFERENCE #3

First Name

Last Name

TITLE

DEPARTMENT

COLLEGE/UNIVERSITY

ADDRESS

Street Address




Postal / Zip Code

TELEPHONE NUMBER

-Area Code

Phone Number

EMAIL ADDRESS

[email protected]

Essays

Attach Documents

Please provide a personal statement of 500 words or less about youracademic and career aspirations including “why you want to be a physician”and “how you will contribute to the development of effective and innovativeapproaches to reduce or eliminate health disparities." *

0/500

In 500 words or less, please explain why you are interested in this programand how this program will help in reaching your academic and career goalsand support the mission of Baylor College of Medicine. *

0/500

OPTIONAL: In 500 words or less, please describe obstacles you haveovercome in your life.

0/500



ADDITIONAL REQUIRED ITEMS

Unofficial Transcripts should be uploaded here. You must include gradesfrom the most recent term. However, you may email the transcript [email protected] if the transcript is not available at the time of thecompletion of your application. You do not need to submit transcripts fromprevious colleges you may have attended IF the LETTER grades appear onyour current transcript.**You will be required to submit an OFFICIAL copy ifyou are selected to participate in the program. *

No file chosenChoose File

Curriculum vitae (or resume) including academic recognition, non-academicrecognition, leadership roles or positions, employment (all paid workexperiences), research activities, community service, andextracurricular/leisure activities. *

No file chosenChoose File

In addition to submitting this application form, you will need to make sure thefollowing materials are received in the Baylor College of Medicine's Center ofExcellence in Health Equity, Training and Research by the March 15 deadline:

1. A completed Dean's Certification and Conduct Check Form confirming that youare in good institutional standing, without professionalism, student conduct orhonor code concerns. This can typically be completed by someone in the Divisionof Student Affairs/Services on your campus. This must be scanned and emailed [email protected] or mailed to:

Baylor College of Medicine Center of Excellence in Health Equity, Training and Research One Baylor Plaza, MS: BCM411 Houston, TX 77030

2. Two letters of support from academic or professional sources using the onineform.

3. Applicants whose native language is not English must take the TOEFL or theIELTS examination to demonstrate proficiency in English (Institution Code 6052 forTOEFL scores). If you hold a degree from a U.S. university or a university at whichinstruction is in English, the exam may be waived. The test must be taken withinthe last two years.

Each eligible applicant who submits a complete application package by thedeadline will be offered a face-to-face interview in Houston by the COE’s TPPAdmissions Committee to discuss their interest in the program and assess non-cognitive skills such as communication skills, maturity and potential for leadershipas a physician.

https://media.bcm.edu/documents/2018/b1/coe-tpp-scholars-dean-of-students-certification-form.pdf

mailto:[email protected]

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ACKNOWLEDGEMENTS & CERTIFICATION

PLEASE READ EACH STATEMENT AND CHECK THE BOX AFFIRMING YOURAGREEMENT: *

IN ADDITION TO THIS APPLICATION FORM, I UNDERSTAND THAT ACOMPLETED "DEAN'S CERTIFICATION AND CONDUCT CHECK FORM" & TWOLETTERS OF SUPPORT FROM ACADEMIC OR PROFESSIONAL REFERENCESMUST BE RECEIVED BY THE APPLICATION DEADLINE (MARCH 15, 2019).

I AFFIRM MY COMMITMENT TO PARTICIPATE IN ALL COE TPP SCHOLARSPROGRAM REQUIREMENTS:

I UNDERSTAND THAT I AM REQUIRED TO ATTEND SESSIONS FROM 8A.M. TO NOON EVERY FRIDAY IN THE FALL 2019 (SEPT.-DEC.) & SPRING2020 (JAN.-MAY).

I UNDERSTAND THAT I WILL BE REQUIRED TO ATTEND THE SCHEDULED20-HOUR/WEEK SESSIONS DURING JULY/AUG. 2019 & JUNE 2020.

I UNDERSTAND THAT IF I AM SELECTED FOR THE PROGRAM I WILL BEREQUIRED TO MAINTAIN HEALTH INSURANCE COVERAGE THROUGHOUTMY PARTICIPATION IN THE PROGRAM.

I UNDERSTAND THAT IF I AM SELECTED FOR THE PROGRAM I WILL BEREQUIRED TO SHOW PROOF OF REQUIRED IMMUNIZATIONS.

I hereby certify that the facts provided pertaining to my application for the BCMCOE TPP program are true and complete to the best of my knowledge. I authorizeinvestigation of all statements contained in this application that may be necessaryin arriving at an acceptance decision. I understand that, if accepted into the BCMCOE TPP program, any false statement on this application, receipt ofunsatisfactory references or transcripts, or failure to provide proof of legalemployment status may result in immediate termination from the program.

I certify that I have read and agree with these statements and this represents myelectronic signature.

ELECTRONIC SIGNATURE: *

Enter Your Full Name

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