ACADEMIC ASSOCIATES Program

ACADEMIC ASSOCIATES Program

APPLICATION
(Fall 2018 Semester)

Applicant Information

/

Re-APPLICANT? Yes NO

if yes what date:

:

:

Mr. Ms. Mrs.
Last Name:
First Name: / M.I.:
D.O.B: / Sex: M F
Street Address: / Apartment unit#:
City: / State: / ZIP:
Social Security No.: / People Soft no.: / Driver’s License no:
Home Phone: / Cell Phone: / Work phone:
Preferred E-mail Address:
Race:
Caucasian / African
American / Hispanic / Asian / Other / If other please specify:

Current Profession/Current Education

Current Employer Name:
CurrentSchool: / Major: / Year In College: / GPA:
What is your pre-health profession? / Pre-Med: / Nursing: / Pre-Dental: / Other:
If other please specify: Honors College:
Have you been provisionally accepted into a combined undergraduate-medical school program?

In Emergency notify:

Full Name: / Relationship:
Phone Home: () / Phone Work: ()
Physician’s Name: / Phone: ()
Do you have documentation of current immunizations? Yes No
MANDATORY: Mantoux Tuberculin Skin Test (current year) Yes No and FLU Shot (During the Season) Yes No
____

Personal Data

Special Skills, Talents, hobbies, interests (crafts, business, or computer skills, etc)
What do you expect from this program/course?
How do you think this program/course would benefit you?
Are you fluent in any Languages? If so please list below.
Prior work experience?
Have you ever been charged with a misdemeanor? Yes NO
Have you ever been charged with a felony? Yes NO
If so please explain.

pLEASE LIST TWO LOCAL PERSONSAL REFERENCES (OTHER THEN FAMILY MEMBERS)

Name: / Phone:
Name: / Phone
PLEASE LIST RELATIVES OR FRIENDS ASSOCIATED WITH TEXAS CHILDREN’S HOSPITAL
(MEDICAL STAFF, EMPLOYEES, BOARD OF TRUSTEES, PATIENTS, OR VOLUNTEERS AND INDICATE RELATIONSHIP)
Name: / Relationship:
Name: / Relationship:

What days and times WOULD YOU BE available to work (6 hour blocks) between the hours of 9am-8pm?

Monday: / Tuesday:
Wednesday: / Thursday:
Friday: / Saturday: Sunday:
PLEASE NOTE:If selectedyou will berequired to: have a current Mantoux Tuberculin Skin Test, Flu shot andbe able toattend the one day Orientation for approximately 8 hours on a Saturday at the Medical Center and attend the monthly Friday lectures/exams from 1-2pm.These requirements are mandatory and you must comply with ALL of them.

Disclaimer and Signature(Please type below)

I certify that my answers are true and complete to the best of my knowledge.
Signature: / Date:

Please e-mail completed application back to Lynette Lister at:

Applications are dueAPRIL 12, 2018

**NOTE: If You Are Accepted You Will Be Notified By Email Within 2-3weeks After The Application Deadline. Otherwise, you were not selected to interview and you are welcome to reapply**