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UCLA PREP Application 2020

Outreach & Pipeline Programs David Geffen School of Medicine at UCLA 885 Tiverton Drive Suite 305 Los Angeles, CA 90095 (310) 825-3575 This application will take about 30-40 minutes to complete. Please make sure you have enough time to complete ALL questions asked. You will be able to save your progress and continue at a later time. To avoid duplicates, you will only able to open one application at a time per device. Things you need to complete the application: Unofficial Transcripts of all schools attended (PDF) Financial Aid Award Letter or FAFSA 2019-2020 Transcript Contact information for your TWO Letter Writers Resume / CV MCAT Score(s) If applicable For any additional questions, please contact us at [email protected] or (310) 825-3575 during our regular business hours, M-F 10am-3pm PST. ALL QUESTIONS MARKED WITH (*) ARE REQUIRED

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Legal Name

o First Name* ________________________________________________

o Last Name* ________________________________________________ Preferred Name (First, Last)

________________________________________________________________ Contact Information*

o Email ________________________________________________

o Phone number (XXX) XXX-XXXX ________________________________________________

What is your current gender identity

o Male

o Female

o Trans male/ Trans man

o Trans female/ Trans woman

o Genderqueer/ Gender non-conforming

o Different identity

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Please select the set of pronouns you want people to use to refer to you

o She/Her/Hers

o He/Him/His

o They/Then/Theirs Birth Information

o Birth date (MM/DD/YYYY)* ________________________________________________

o Birth Country* ________________________________________________ For any additional questions or concerns regarding the application, please contact us at [email protected] or (310) 825-3575 during our regular business hours, M-F 10am-3pm PST.

Have you previously applied to Medical School (MD or DO) in the United States*

o Yes

o No For any additional questions or concerns regarding the application, please contact us at [email protected] or (310) 825-3575 during our regular business hours, M-F 10am-3pm PST.

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Have you taken the MCAT?*

o Yes

o No

o No, but I have registered to take the MCAT Most Recent MCAT Test Date / Anticipated Test Date (MM/DD/YYYY)

________________________________________________________________ MCAT Score breakdown

o Total Score ________________________________________________

o Chemical and Physical Foundations of Biological Systems ________________________________________________

o Critical Analysis and Reasoning ________________________________________________

o Biological and Biochemical Foundations of Living Systems ________________________________________________

o Psychological, Social, and Biological Foundations of Behavior ________________________________________________

For any additional questions or concerns regarding the application, please contact us at [email protected] or (310) 825-3575 during our regular business hours, M-F 10am-3pm PST.

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High School*

o Country ________________________________________________

o Graduation Year ________________________________________________ College Attended 1*

o Country ________________________________________________

o Program Type (Graduate/Junior College/Postbacc/Undergraduate) ________________________________________________

o Start Date (MM/YYYY) ________________________________________________

o End Date/Expected Graduation (MM/YYYY) ________________________________________________

o Degree Received? (Yes/No) ________________________________________________

o If answered Yes above, specify type of Degree Received (AA, BS, BA, MS, etc). Input N/A if not applicable) ________________________________________________

o Major ________________________________________________

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College Attended 2

o Country ________________________________________________






o Major ________________________________________________ College Attended 3

o Country ________________________________________________






o Major ________________________________________________

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Do you need to add more schools?

o Yes

o No College Attended 4

o Country ________________________________________________






o Major ________________________________________________

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College Attended 5

o Country ________________________________________________






o Major ________________________________________________ For any additional questions or concerns regarding the application, please contact us at [email protected] or (310) 825-3575 during our regular business hours, M-F 10am-3pm PST.

Preferred Address*

o Country ________________________________________________

o Address ________________________________________________

o Address 2 (type N/A if not applicable) ________________________________________________

o City ________________________________________________

o State ________________________________________________

o Zip Code ________________________________________________

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Citizenship*

o US Citizen

o Permanent Resident

o Deferred Action for Childhood Arrival (DACA)

o Other (Specify Below) Citizenship Other (Specify Below):

________________________________________________________________ Self-identification: How do you self-identify?

▢ Hispanic, Latino, or of Spanish origin

▢ American Indian or Alaska native

▢ Asian

▢ Black or African American

▢ Native Hawaiian or other Pacific Islander

▢ White

▢ Other Self-identification Other (Specify Below):

________________________________________________________________

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Languages: Please add all the languages you speak, including English . Please use these answer choices below as a guide. Proficiency: Basic, Fair, Good, Advanced, Native/Functionally Native Use in Childhood Home: Never, rarely, from time to time, Often, Always Language 1 (Please Input ENGLISH)

o Language ________________________________________________

o Proficiency ________________________________________________

o Use in Childhood Home ________________________________________________ Do you speak any other language(s) other than English?*

o Yes

o No Language 2

o Language ________________________________________________

o Proficiency ________________________________________________

o Use in Childhood Home ________________________________________________

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Language 3

o Language ________________________________________________

o Proficiency ________________________________________________

o Use in Childhood Home ________________________________________________ Language 4

o Language ________________________________________________

o Proficiency ________________________________________________

o Use in Childhood Home ________________________________________________ Childhood Information In what area did you spend the majority of your life from birth to age 18?*

o Country ________________________________________________

o City ________________________________________________

o Description (Rural, Suburban, Urban) ________________________________________________

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Do you believe that this area was medically under-served?*

o Yes

o No

o Do not know

o Decline to Answer Have you or members of your immediate family ever used federal or state assistance programs?*

o Yes

o No

o Do not know

o Decline to Answer

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What was the income level of your family during the majority of your life from birth to age 18?*

o Do not know

o Less than $25,000

o $25,000 - 49,999

o $50,000 - 74,999

o $75,000 - 99,999

o $100,000 - 124,999

o $125,000 - 149,999

o $150,000 or more

o Decline to answer Did you have paid employment prior to age 18?*

o Yes

o No

o Decline to Answer How many people lived in your primary household during the majority of your life from birth to age 18?*

________________________________________________________________

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Were you required to contribute to the overall family income (as opposed to working primarily for your own discretionary spending money)?*

o Yes

o No

o Decline to Answer Did you received a Pell Grant at anytime while you were an undergraduate student?*

o Yes

o No

o Decline to Answer Have you paid or did you pay for your post-secondary education? For each of the applicable options below, indicate the average percentage contribution towards your post-secondary education.

0 10 20 30 40 50 60 70 80 90 100

Academic Scholarship

Financial Need-Based Scholarship

Student Loan

Other Loan

Family Contribution

Applicant Contribution

Other

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Military Service: Have you or are you currently serving in the United Stated Military?*

o Yes

o No

o Decline to Answer Felony: Have you ever been convicted of, or pleaded guilty or no contest to, a Felony crime, excluding 1) any offense for which you were adjudicated as a juvenile, or 2) convictions which have been expunged or sealed by a court (in states where applicable)?*

o Yes

o No Misdemeanor: Have you ever been convicted of, or pleaded guilty or no contest to, a misdemeanor crime, excluding 1) any offense for which you were adjudicated as a juvenile, or 2) convictions which have been expunged or sealed by a court 3) any misdemeanor convictions for which any probation has been completed and the case dismissed by the court (in the states where applicable)?* Disadvantaged Status: The following definitions/questions may help you answer the questions on this page: Underserved: Do you believe, based on your own experiences or the experiences of family and friends, that the area in which you grew up was adequately served by the available health care professionals? Were there enough physicians, nurses, hospitals, clinics, and other health care service providers? Immediate Family: The Federal Government broadly defines "immediate family" as "spouse, parent, child, sibling, mother or father-in-law, son or daughter-in-law, or sister or brother-in-law, including step and adoptive relationships." State and Federal Assistance Programs: These programs are specifically defined as "Means-Tested Programs" under which the individual, family, or household income and assets must be below specified thresholds. The sponsoring agencies then provide cash and non-cash assistance to eligible individuals, families, or households. Such programs include welfare benefit

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programs (federal, state, and local) Aid to Families with Dependent Children (AFDC or ADC); unemployment compensation; General Assistance (GA); food stamps; Supplemental Security Income (SSI); Medicaid; housing assistance; or other federal, state, or local financial assistance programs. Do you consider yourself as a disadvantaged applicant (social, economic, or educational)?*

o Yes

o No Please use this space to explain why you believe you should be considered as a disadvantaged applicant:

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________ Parents and Guardians If unable to provide parent/guardian information, please put N/A in all the boxes

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Parent/Guardian 1*

o Name ________________________________________________

o Occupation ________________________________________________

o Living (Yes or No) ________________________________________________

o Highest Educational Level ________________________________________________ Parent/Guardian 2

o Name ________________________________________________

o Occupation ________________________________________________

o Living (Yes or No) ________________________________________________

o Highest Educational Level ________________________________________________ Dependents: How many dependents do you have?

________________________________________________________________ For any additional questions or concerns regarding the application, please contact us at [email protected] or (310) 825-3575 during our regular business hours, M-F 10am-3pm PST.

Work/Activities (You can add up to 5 most relevant experiences) For experience type please choose from the following options: Artistic Endeavors Community Service/Volunteer - Medical/Clinical

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Community Service/Volunteer - Not Medical/Clinical Conferences Attended Extra Curricular Activities Honors/Award/Recognition Intercollegiate Athletics Leadership - Not Listed Elsewhere Military Service Other Paid Employment - Medical/Clinical Paid Employment - Not Medical/Clinical Presentation/Posters Publication Research/Lab Teaching/Tutoring/Teaching Assistant Work/Activity 1

o Experience Type (select from categories above) ________________________________________________

o Experience Name ________________________________________________


o End Date (MM/YYYY) ________________________________________________

o Organization Name ________________________________________________

o Country ________________________________________________

o State ________________________________________________

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Work/Activity 2




o End Date (MM/YYYY) ________________________________________________


o Country ________________________________________________

o State ________________________________________________ Work/Activity 3




o End Date (MM/YYYY) ________________________________________________


o Country ________________________________________________

o State ________________________________________________

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Work/Activity 4




o End Date (MM/YYYY) ________________________________________________


o Country ________________________________________________

o State ________________________________________________ Work/Activity 5




o End Date (MM/YYYY) ________________________________________________


o Country ________________________________________________

o State ________________________________________________ For any additional questions or concerns regarding the application, please contact us at [email protected] or (310) 825-3575 during our regular business hours, M-F 10am-3pm PST.

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Letters of Recommendation: Two (2) letters of recommendation, one from a science professor and one from a counselor / premedical advisor or employer/internship recommending participation in the PREP Program. Please ensure that the email address below is accurate. Letter writers will receive a separate email with instructions on how to submit their letter of recommendation. Please advise them before hand to check their emails as soon as you submit. Letter Writer 1*

o First Name ________________________________________________

o Last Name ________________________________________________

o Title ________________________________________________


o Phone ________________________________________________

o Email ________________________________________________ Letter Writer 2*

o First Name ________________________________________________

o Last Name ________________________________________________

o Title ________________________________________________


o Phone ________________________________________________

o Email ________________________________________________

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For any additional questions or concerns regarding the application, please contact us at [email protected] or (310) 825-3575 during our regular business hours, M-F 10am-3pm PST.

Supporting Documents: Please upload all of the following documents in PDF format. Unofficial Transcript(s) from all colleges and universities attended. Financial Aid award letter from your current institution. Upload FAFSA 2019-2020 transcript if financial aid award letter is not available. Essay describing your personal, family, and community background; your motivation for medical career; what you have done to develop your interest and knowledge of modern medicine; and what you hope to accomplish by participation in UCLA PREP (minimum 1000 words, maximum 1500). Unofficial Transcript 1* Do you need to add more transcripts?*

o Yes

o No Unofficial Transcript 2 Unofficial Transcript 3

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Unofficial Transcript 4 Financial Aid Award Letter or FAFSA 2019-2020 Transcript* Essay: minimum 1000 words, maximum 1500 words.* For any additional questions or concerns regarding the application, please contact us at [email protected] or (310) 825-3575 during our regular business hours, M-F 10am-3pm PST.

Signature and Confirmation I declare that the applicant has provided correct information in this application form. I have checked and verified the application and any supporting documents. I hereby take full responsibility for any wrong verification made, or wrong documents submitted for the application.* Submission Date (MM/DD/YYYY)*

________________________________________________________________ For any additional questions or concerns regarding the application, please contact us at [email protected] or (310) 825-3575 during our regular business hours, M-F 10am-3pm PST.