Instructions for Completing the UCHO Student Data Sheet

1.) Complete the following form. DELETE all instructions in italics.

2.) TYPE, PRINT, and COMPLETE the Student Data Sheet and submit to the Office of Optometry Relations by February 15, 2017 at 5:00 p.m. Place your form in the tray at the front desk, face down.

DO NOT submit Instruction page with your student data sheet.

The Student Data Sheet can be found on the UHCO website at http://www.opt.uh.edu/students/scholarships.cfm

The Optometry Student Data sheets are intended for the purpose of scholarship nominations.

Only the faculty and the Scholarship & Financial Aid Committee will view your information.

If you have any questions regarding this form, contact Ashley Olheiser, .

Student Data Sheet

Present Optometry Level / Optometry I, II III or IV
City & State of Permanent Residence / List your city and state of permanent residence.
Name
PeopleSoft ID / Full name, as it appears in UHCO registration. If desired, include nickname or maiden name in parenthesis.
PeopleSoft Identification Number
Gender / Male or Female
Degrees Received / List all degrees received and the college/university from which they were conferred.
Awards and Recognition / List all awards and recognition received.
Memberships / List all organizations and societies of which you are a member.
Leadership Positions / List all leadership positions held, school related and extracurricular.
Publications / List any publications in which you are listed as author or contributor.
Work Experience / List any paid positions held since entering Optometry School. Include any UHCO TA, research, grader or tutor positions held.
College Service/
Community Service / List any community service work performed and involvement in university committees/ activities/events.

last revision ______It is the student’s responsibility to update his/her data sheet on a yearly basis.

THIS SECTION TO BE COMPLETED BY OFFICE OF OPTOMETRY RELATIONS

Cumulative GPA ______Initial ______

Confidentiality Notice

The Optometry Student Data Sheets are intended only for the purpose of scholarship nominations. This information will be viewed by the faculty and Scholarship & Financial Aid Committee only.