2013 Application

Cancer & Health Disparities Summer Internship Program

University of Minnesota

Please email your completed application as an attachment by 4:00 p.m. on Thursday, February 14, 2013

To: Sandra Rivera

Email:

For additional questions, please email or call 612-625-4441.

Full Legal Name

Last Name
First Name
Middle Name

Your Contact Information

Campus e-mail
Personal e-mail
(Many campuses will not allow large volumne emails; therefore, this optional email may be necessary.)
Preferred phone number
Campus mailing address
Home mailing address

Backup/Family Contact Information
Please select one person whom we may contact to give you a message if needed.

Contact's Name
Relationship to You
Telephone Number
Email Address

Describe Your Family

Number of adults and children in your immediate family: / Adults (over age 18)
Children (17 or younger)
Mother's education background: Select one and delete the other choices
/ Did not complete high school
Completed High School
Completed an Associate Degree (2-Year)
Completed a Bachelors Degree
Completed a Masters Degree
Completed a Doctoral/Professional Degree
Mother's profession/work:
Mother’s annual income (estimated, before taxes):
Father’s education background: Select one and delete the other choices
/ Did not complete high school
Completed High School
Completed an Associate Degree (2-Year)
Completed a Bachelors Degree
Completed a Masters Degree
Completed a Doctoral/Professional Degree
Father’s profession/work:
Father’s annual income (estimated, before taxes):
Does your family participate in any programs designated for low-income and/or working families? If yes, describe them: (Examples: Free or reduced lunches for children, ACT or SAT fee waiver, food stamps, your current involvement in TRIO or related programs)

Demographic Information

Date of Birth (mm/dd/yyyy)
Gender
Ethnicity and Race
The information provided below is voluntary and will not be used in a
discriminatory manner. The questions below comply with the U.S. Department of Education’s new mandated standards for ethnic and racial data collection. / 1. Ethnicity: Are you Hispanic or Latino?
No Yes (if Yes, please skip #2 below)
2. Race: Please check any or all that apply.
American Indian or Alaska Native
Asian
If Asian, do you consider yourself:
Chinese
Hmong
Japanese
Korean
Lao
Thai
Vietnamese
Other: Please describe:
Black or African American
If Black, do you consider yourself:
Ethiopian
Liberian
Nigerian
Oromo
Somali
Other: Please describe:
Native Hawaiian or Other Pacific Islander
White
Two or more races. Please describe:
I grew up in this setting:
Rural environment (community of less than 30,000 people within Minnesota)
Suburban environment (not the actual cities of Minneapolis or St. Paul)
Urban environment (Minneapolis or St. Paul)
Rochester, St. Cloud and Duluth do not fit these categories above. Please select one of those cities individually. / Please select one of the following (erase all others):
Rural Minnesota
Urban Minnesota - Minneapolis or St. Paul (select one)
Suburban Minnesota
Rochester, Duluth or St. Cloud (select one)
Other (please explain):

Citizenship

Citizenship / Please select one of the following (erase all others):
U.S. Citizen
Permanent Resident
Temporary or nonimmigrant visa holder
Refugee/political asylee
Other (please explain)
If you are not a U.S. citizen, of what country are you a citizen?
State in which you claim legal residence / Please select one of the following (erase other choice):
Minnesota
Other (please explain)
How long have you lived in Minnesota?

High School Education

What year did you graduate from high school?
Name of High School
City and State of High School
What was your cumulative high school GPA?
What courses did you most enjoy as a high school junior and senior? / Provide four examples of your favorite courses:
Did you take Post Secondary Enrollment Options (PSEO), College in the Schools, Advanced Placement (AP), International Baccalaureate (IB), or any college equivalent coursework while in high school?
/ If yes, describe your coursework:
What was your ACT score? / Provide score here:
Or select, I did not take the ACT
What was your SAT score? / Provide score here:
Or select, I did not take the SAT
What school-sponsored clubs/activities were you involved in while attending high school? What years?
What offices did you hold in your high school sponsored clubs or activities? What years?

College/University Education

Current College/University
(If you are a U of M, Twin Cities student – please state U of M, Twin Cities and provide your college)
Intended Graduation (Month, Year)
Major
Minor
What is your cumulative college/university GPA?
What college/university-sponsored clubs/activities are you currently involved in?
What offices do you hold within these clubs and organizations?

Work Experience

What paid work experiences/jobs have you had in the last three years?
Or, what unpaid work have you done? (Examples include: working in a family business or taking care of a younger sibling/elderly adult.)
Please give the beginning and end dates of all positions you held and estimate how many hours each week you spent at each job/position.

Community Service/Volunteering Experience

What community service and volunteer activities have you been involved in over the last three years (and what are you involved in currently)?
Please give the beginning and end dates of each service you provided and estimate how many hours per week you served/volunteered within each setting.

Awards and Achievements

What awards or achievements have you received within the last three years?
Who gave these awards/achievements? What year were they granted?

How Did You Learn About this Opportunity?

How did you find out about this program? Where did you learn about the Cancer Health Disparities Summer Internship (who was the first person to introduce you to the concept/when/how)?
Written Essay
Please respond using no more than 500 words for the following essay question. This essay is an essential piece of your application. College-level spelling and sentence structure is expected.
[Helpful Hint: To learn how many words you have written, use Microsoft Word’s word count tool. Click on Tools, and then choose Word Count. Some newer Microsoft Word systems may have different means for doing a word count.]
Essay Question:
We seek individuals who plan to become healthcare professionals or researchers or serve the diverse communities within our state. Take a moment to think about a specific diverse or underserved community within Minnesota and how it is impacted by cancer. Describe the most critical health issues facing this Minnesota community and how you would serve in this area of need.

Your essay goes here.

Your College/University Transcript
Please cut and paste your unofficial college transcript here. You may access it from your college/university online course planner or student services web site.

Paste your unofficial college transcript here.

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