2016-2017 Academic Year
Only accepting applications for Units 2, 3, and 4
(As of 5-24-16) /
university health services @ Cal
Instructions: Fill out this application and complete the four short answer questions. Please email your completed application to . All fields are required (except where noted) – failure to complete all required fields may jeopardize processing or consideration of your application. PLEASE BE SURE TO ANSWER ALL QUESTIONS!
Applicant Information
Name (as appears on UCB records)
UCB Student ID Number
Current Class Level q frosh q soph q junior q senior q grad q spouse
First Semester at Cal (e.g. Fall 2007) Did you transfer? q yes q no
Expected Semester of Graduation
College (e.g. L+S) and major
Birthday (month, day) /
Campus Contact Information
Current living center
Name & email for RA, House Mgr, etc
(may be contacted as a reference)
Current Local Address
City, State, Zip Code
Cell Phone ( ) Voicemail? q yes q no
Primary E-mail Address
Position Interest
RESIDENCE INFORMATION: Please indicate where you plan to live during the 2016-17 academic year. Though everyone will be considered, priority will be given to individuals living in a residence where we need more Health Worker representation.
HOUSING INFORMATION:
Have you already submitted your application for housing for the 2016-2017 academic year? (Check one.)
q I have already submitted my housing application.
q No, I have not yet submitted my housing application, yet I intend to live on campus..
WHERE DO YOU PLAN ON LIVING?
International House: What Floor? ______
Unit 1 Residence Halls: What building? ______
Unit 2 Residence Halls: What building? ______
Unit 3 Residence Halls: What building? ______
Unit 4 Residence Halls: What building? ______
Unit 5 Residence Halls: What building? ______
Martinez Commons: Rooms or Apts? ______
Other :
Willing to relocate if needed?
Scheduling Availability
Please describe your current academic plan for the 2016-2017 academic year (include # of units).
Will you be taking any graduate school exams and/or prep courses between June 2016 and May 2017? If so, please list and indicate any dates and/or times that involves.
What other activities (e.g. jobs, internships, clubs, positions, trips) will you be involved in during the 2016-2017 academic year? How many hours do you anticipate that each will require?
During the 2016-17 academic year:
Can you commit 8 hrs/week? q yes q no
Can you attend HW Fieldwork Class every Tuesday from 5-6:30pm q yes q no
Can you attend living center activities and meetings on Tues eve after 7pm? q yes q no
Are you available Tuesday May 3rd, 2016 from 4-6pm for orientation? q yes q no
Are you available August 19-20, 2016 all day for Fall Training? q yes q no
Are you available August 21-23, 2016 for Getting Your Bearings Activities? q yes q no
Short Answer Questions
Please complete each of the following questions with 200 words or less.
1. Have you ever sought information or help from a Health Worker? Describe why or why not.
2. What are your current goals and plans after graduation?
3. What are 2-3 top health issues in your current living community? On what do you base your answer?
4. Choose one of the health issues named above and write the text for a 200 word “Health Tip” relevant for your community that promotes prevention and early intervention (self-care and health-care) on the topic. Include an example of a time you noticed and helped someone with a related issue.
Interview & Selection Process
Following review of your application, you will be notified of the next steps in the selection process.