YSU-BaccMed Application for 2017–2018

This application assumes you have already applied to YSU and we have all your transcripts, high school and/or college.

PLEASE: send us an application only if your intention is to be in YSU-BaccMed—providing we make you a program seat offer. Application deadlines: Fall admissions cycle, 15 November 2016; Spring admissions cycle, 15 March 2017.

General Information
Preferred Name:
Social Security Number:
Gender:
Date of Birth:
First Generation college student?
Signature:
Date: / Home Address:
Lived here how long:
Home Phone:
Cell:
Email:
Racial/Ethnic Background
Ethnicity:
American Indian or Alaska Native:
Asian or Pacific Islander:
Black or African American:
Hispanic:
Mainland Puerto Rican:
Mexican American:
White:
Unknown/Decline to respond:
Note: “African-American” includes descendants of American slaves as well as descendents of African immigrants. / Citizenship
Citizenship Status:
Ohio Resident:
Currently living in US:
Birth City:
Birth State:
Birth Country:
Permanent Resident/Visa
Issue Date:
Expiration Date:
Visa Type:
Alien Registration Number:
Native Language:
High School
School:
Home Schooled:
Attended from:
Attended until:
Transcript GPA:
Class Rank:
Class Size:
For Office Use Only:
Calculated GPA (4-point scale):
Calculated BCPM (4-point scale): / ACT Scores (please enter in spaces provided)
Composite , Math , Science , Reading , English
Test date of highest ACT composite:
SAT Scores (please enter in spaces provided)
Composite , Math , Verbal
Test date of highest SAT composite:
Medical Professions/Interests: Check each in which you are interested:
□ Primary care
□ Medically underserved communities
□ Research related to / supporting primary care and
medically underserved communities
Parent 1
Relationship:
Name:
Email:
Employer:
Occupation:
Education:
Living:
Address:
City:
State:
Zip Code:
Country:
Address outside of US or Canada? / Parent 2
Relationship:
Name:
Email:
Employer:
Occupation:
Education:
Living:
Address:
City:
State:
Zip Code:
Country:
Address outside of US or Canada?
Extracurricular Activity I
Type of Experience:
Date Range:
Hours:
Brief Description: / Extracurricular Activity II
Type of Experience:
Date Range:
Hours:
Brief Description:
Extracurricular Activity III
Type of Experience:
Date Range:
Hours:
Brief Description: / Extracurricular Activity IV
Type of Experience:
Date Range:
Hours:
Brief Description:
Extracurricular Activity V
Type of Experience:
Date Range:
Hours:
Brief Description:
/ Extracurricular Activity VI
Type of Experience:
Date Range:
Hours:
Brief Description:

ESSAYS: Please tailor your responses to fit into the provided spaces.

Essay 1
Have you ever held a part-time job? If so, please describe each such job and what you have learned from that experience.
Essay 2
Describe your interest in primary care using specific examples. Primary care includes: family medicine, general internal medicine, general pediatrics; medically underserved populations, including rural and urban communities; research related to above medical areas and underserved populations.
Essay 3
What is your view of healthcare access, and how is your view of medically underserved communities informed by your experiences?