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ProgramRealizingEducationalPotential(PREP)

The Program Realizing Educational Potential (PREP) at Northern Arizona University offers students from disadvantaged backgrounds the opportunity to prepare for a future career in the health professions. Selected participants will meet role models who also come from disadvantaged backgrounds, work with health professionals, participate in academic development, and get a head start in preparing for college.

This four-and-a-half-week summer program is held on the NAU campus Mondays through Saturdays, June 1 to July 1, 2016. Scholars receive a $3,600 stipend that can be used toward housing, meals, and transportation to and from campus, and are required to participate in all planned activities. Upon completion of PREP and pre-requisite courses, the scholars are encouraged to apply to a health profession program at Northern Arizona University. The program is sponsored by a federal grant from the Health Resources and Services Administration, #D18HP29041, called the Journey for Underrepresented Medical Professionals (JUMP).

Because JUMP is a pathway for students from disadvantaged backgrounds to work toward a future career in the health professions, applicants must provide documentation showing they are from a disadvantaged background or from a community with a shortage of health care professionals. The U.S. Department of Health and Human Services defines disadvantaged as: • Educationally disadvantaged: Coming from an environment that has inhibited

the individual from obtaining the knowledge, skills, and abilities necessary todevelop and participate in a health professions education or training program.

• Economically disadvantaged: Coming from a family with an annual incomebelow a level based on low-income thresholds according to family size publishedby the U.S. Bureau of Census, adjusted annually for changes in the ConsumerPrice Index, and adjusted by the Secretary of the U.S. Department of Health andHuman Services, for use in all health professions programs.

Journey for Underrepresented Medical Professionals PO Box 15065 Flagstaff, AZ 86011 (928) 523-7047 Christal.Black@nau.edunau.edu/JUMP

Circumstances that might meet the disadvantaged criteria are outlined below:

Educational Background: • Attended under-performing high school. Under-performing rating is high school specific

, not rating for school district or state.o For Arizona resident documentation can be your high school report card and high

school Achievement Profile at: azed.gov/srcs/find_school.aspo If you are not from Arizona, go to your state’s Department of Education website and

look for your high school report card.o A federal site that might provide information is: nces.ed.gov/nationsreportcard/

• Graduated from or last attended a school with:o Low SAT scores based on most recent data availableo Low percentage of seniors receiving a high school diplomao Low percentage of graduates going to college during their first year after graduationo Low per capita fundingo Many of the enrolled students are eligible for free or reduced price lunches (generally

more than 50%) Documentation and can be found at:azed.gov/health-nutrition/frpercentages

• Raised by single parent due to death of one parent. Must provide copy of death certificate.• Family receives public aid such as food stamps, Medicaid/AHCCCS or other type of federal/

state insurance, public housing, free school lunch, etc.• Both parents’ highest level of education is high school degree or lower. Documentation can

be found on your FAFSA- Student Aid Report (SAR).• Lived in an area that is considered by the Federal government as a rural area. See

hrsa.gov/ruralhealth/aboutus/definition.html and click on Rural Health Grants EligibilityAdvisor and enter the address where you were raised.

• Raised or worked in Medically Underserved Community (MUC) or Health ProfessionalShortage Area (HPSA). Documentation of shortage designations can be found at:datawarehouse.hrsa.gov/tools/analyzers/geo/shortageArea.aspx or bhpr.hrsa.gov/shortage

• Economic background: Need is determined upon submission of the Free Application forFederal Student Aid (FAFSA) at fafsa.gov, using NAU school code: 001082. Attach theFAFSA Student Aid Report (SAR) to this application.

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Journey for Underrepresented Medical Professionals PO Box 15065 Flagstaff, AZ 86011 (928) 523-7047 Christal.Black@nau.edunau.edu/JUMP

Family Background:

1) Application form2) Essay3) A copy of recent high school or college/university transcripts

(unoffical is acceptable)4) Resume

A Completed application includes the following: *All Materials must be submitted together in one packet to be considered*

Thank you for your applying

Please mail or email completed form to Christal Black

PO Box 15065, Flagstaff, AZ, 86011

Christal.Black@nau.edu (928) 523-7047

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Family Background:Select one or more of the criteria appropriate for your circumstance:

Raised by single parent due to death of one parent.

Family receives public aid.

Both parents highest level of education is high school or lower.

Lived in an area considered rural by the Federal government.

Raised in a MUC or HPSA community.

Please attach as a separate page any other factor that may identify you as from a disadvantaged background based on the U.S. Department of Health and Human Services definition.

Other Background:

Participants receive a $3,600 stipend that can be used toward housing, transportation to and from campus, and meals. On-campus housing is available for reduced rates.

Will you need summer housing at NAU? ☐ YES ☐ NO

Have you applied for admission to NAU? ☐ YES ☐ NO If yes, when? _____________

Are you a 2NAU student? ☐ YES ☐ NO If yes, at what community college?______________

Have you been convicted of a felony or DUI within the past 7 years? ☐ YES ☐ NO ?

ProgramRealizingEducationalPotential(PREP)Application Completeeachitemtothebestofyourknowledge.Incompleteapplicationswillnotbeconsidered.

SelectedapplicantswillbenotifiedbyemailinApril.

Address: City: State: Zip:

PART I – BACKGROUND Application Deadline: April 22, 2016Please mark all that apply and include documentation to support the disadvantage criteria: Educational Background:

High School name:

Fill out the text box below if you meet other educational background listed above:

Journey for Underrepresented Medical Professionals PO Box 15065 Flagstaff, AZ 86011 (928) 523-7047 Christal.Black@nau.edunau.edu/JUMP

PART II – GENERAL INFORMATION

Name: (Last, First, MI) Male Female

Email Address: Date of Birth:

CURRENT ADDRESS Street or P.O. Box #:

City State Zip ?

SUMMER ADDRESS Street or P.O. Box #:

City State Zip ?

Shipping Address (for FEDEX type mailings) Street ?

City State Zip ?

Contact numbers Telephone: ( ) ?

Message: ( )

Shipping Address (for FEDEX type mailings) Street? ?

City State Zip ? ?

Contact numbers Telephone: ( ) ?

Message: ( )

Part IV – EDUCATIONAL BACKGROUND

School currently attending: Cumulative GPA:

Address: City: State: Zip:

Year in School: College Major:

List any honors or awards you have received:

List clubs or associations you are affiliated with:

List other extracurricular activities:

U.S. Citizen

NoIfyes,Whichbranch? ________________________________Yes

U.S. National : Yes No Lawful Permanent Resident: Yes NoIf yes, indicate country of birth _______________________

NotHispanic,Latino,orSpanishoriginHispanic,LatinoorSpanishorigin

BlackorAfricanAmericanNativeHawaiianorotherPacificIslanderWhiteUnknownMorethanoneracepleaselist________________

AmericanIndianorAlaskanNativeAsiansuchasChinese,Japanese,Korean,

Filipino,AsianIndian,orThai Asian(underrepresented)fromFarEast

Asia,SoutheastAsia,ortheIndiansubcontinentotherthanthoseabove

NoYes

Ethnicity (please check one):

Race(pleasecheckone):

Veteran: Citizenship:

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Journey for Underrepresented Medical Professionals PO Box 15065 Flagstaff, AZ 86011 (928) 523-7047 Christal.Black@nau.edunau.edu/JUMP

PART III – DEMOGRAPHICS

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PART V – SCHOOL TRANSCRIPT Please have unofficial high school or college transcripts sent to: Christal Black, NAU Journey for Underrepresented Medical Professionals, PO Box 15065, Flagstaff, AZ 86011

Part VI – ESSAY Write a one- to two-paragraph essay on how your participation in the PREP program will assist you in achieving your educational goals and aspirations. Describe your career interests and motivations, and explain why you’re interested in a career in the health professions.

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Journey for Underrepresented Medical Professionals PO Box 15065 Flagstaff, AZ 86011 (928) 523-7047 Christal.Black@nau.edunau.edu/JUMP

By signing below:

• I hereby affirm that the above information to be complete and accurate to the best of my knowledge.• I also understand that all above information may be subject to verification and review.• Falsified information will result in forfeiture of any awarded funds.• I agree to submit information and contact information following program completion.

Student’s Signature ________________________________________ Date __________________

Parent’s Signature ________________________________________ Date _________________*Required for minors under 18 years of age*