Application deadline: january 17, 2014 (Late applications will be reviewed on space available basis) Questions? Please call: Selma High School: (559) 495-6416
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APPLICATION DEADLINE: JANUARY 17, 2014 (Late applications will be reviewed on space available basis) Questions? Please call: Selma High School: (559) 495-6416 University of California, San Francisco, Fresno Latino Center for Medical Education and Research (LaCMER) D O C T O R S A C A D E M Y Admission Applicationfor Selma High School2014 – 2015 DEADLINE: JANUARY 17, 2014Participating Schools: Caruthers High School Selma High School Key Partners: University of California, San Francisco School of Medicine University of California, San Francisco Medical Education Program Fresno University of California, San Francisco School of Pharmacy University of California, San Francisco School of Dentistry California State University, Fresno University of California, Merced Fresno County Office of Education Caruthers Unified School District Fresno Unified School District Selma Unified School District Community College State Center District Community Regional Medical Centers Kaiser Permanente, FresnoFunded in part by, University of California, San Francisco, School of Medicine The California Wellness Foundation OSHPD Wells Fargo Bank The California Endowment
Under the auspices of the University of California, San Francisco, Fresno Latino Center for Medical Education and Research, the Doctors Academy is a health professions preparatory high school program. Applicants who are educationally OR economically disadvantaged, and who express an interest in a health professional career are eligible to apply. Participants of the Doctors Academy must be United States citizens, non-citizen nationals, or foreign nationals who possess a VISA permitting permanent residence in the United States. ___Educationally Disadvantaged: For the purpose of program eligibility, an applicant is considered educationally disadvantaged if he or she is the first in the immediate family to pursue a BA/BS degree or higher. [Applicants who have at least one parent/guardian with a BA/BS degree or higher are considered ineligible for the Doctors Academy program.] - OR - ___Economically Disadvantaged: For the purpose of program eligibility, an applicant is considered economically disadvantaged if he or she was eligible for the Free and Reduced Lunch Program (Title I services) during the 8th grade year. [Applicants who did not qualify for Title I services due the parent/guardian income level are considered ineligible to apply for the Doctors Academy program.] IF YOU ARE ELIGIBLE, PLEASE CONTINUE WITH THE APPLICATION PROCESS Selection criteria is based on: GPA of 2.8 or better ● Personal Statement Two Letters of Recommendation ● Personal Interview Health Disparity Essay ● A writing sample may be required for finalists The mission of the Doctors Academy is: 1. To increase the number of students who graduate from high school and go on to a university to become competitive applicants to health profession schools. 2. To strengthen the educational pipeline of under-represented or disadvantaged students throughout Fresno County and encourage them to enter a health profession.
Enroll in the most rigorous, accelerated classes with an emphasis on math, science, and English. (Honors & Advanced Placement) Commit to the Doctors Academy five-year study plan Maintain a 2.8 academic grade point average (GPA) Participate in summer enrichment and summer school programs Participate in study academies, study trips, and other activities Students accepted into the Doctors Academy will be responsible for their own transportation. Students who are dropped or choose to withdraw from the Doctors Academy program will return to their home high school if it is other than the Doctors Academy site. The information requested is in compliance with the “Health Professionals Education Partnerships Act of 1998” P.L. 105-392, reauthorized and amended section 739 of the PHS Act (Educational Assistance in the Health Professions Regarding Individuals from Disadvantaged Backgrounds). STUDENT INFORMATION Academic Enrollment Year 2014-2015 – Selma High School Entering Grade Level: 9th Student ID#:___________ Name: __________________________________________________________________ Male ___ Female ____ Date of Birth (mo/day/year): _____________________ Social Security #:_(only list the last four digits) XXX-XX-______ Address: ___________________________________________________________City: _________________ Zip Code: ______ Home Phone #: ___________________________________ Cell Phone # _______________________________ Email address: _____________________________________________________________________________ Middle School: __________________________________________________________________ Current GPA: _______ Home High School for 2014-2015:_______________________________________________________________________________ Indicate the health or medical profession are you most interested in: ______________________________________ Student Signature ____________________________________________________________________Date__________________ PRIMARY PARENT(S)/GUARDIAN(S) INFORMATION Father’s/Guardian Name: ___________________________________Work phone #__________________ Cell # ____________________ Mother’s/Guardian Name: __________________________________Work phone #__________________Cell # ____________________ Legal Parent/ Guardian Address: _____________________________________________City: _________________ Zip Code: ________ Email address: __________________________________________________________________________ Child’s Ethnicity (for statistical purposes only): ___ African-American ___ American Indian ___ Caucasian ___Latino ___ Asian: □Chinese □Japanese □Korean □Cambodian □Hmong □Laotian □Thailand □Philippine Islands □Vietnamese □Asian Indian
Language most frequently spoken at home: ________________________________ Preferred language for written materials: ________________________________ Did your child qualify to receive reduced or free lunch during the 2013-14 School Year? __ Yes __ No Highest level of education completed by: Mother/Guardian Father/Guardian __ Did not finish high school __ High school graduate __ Did not finish high school __ High school graduate __ Some college __ AA/AS Degree __ Some college __ AA/AS Degree __ BA/BS Degree __ Master’s Degree __ BA/BS Degree __ Master’s Degree __ Doctorate Degree __ Doctorate Degree
Why you have chosen to apply to the Doctors Academy. How you have prepared yourself academically for high school. Tell us about your talent, experience, personal quality and the contributions you would bring to the Doctors Academy. HEALTH DISPARITY ESSAY Essay 2. On a separate sheet, please provide a minimum of two paragraphs that describe the following: In your own words, please define health disparity Provide an example of at least one health disparity within your community. (Please type or print legibly in ink.) Student’s Name: _______________________________ (Must be from a Math, Science or English Teacher) DUE BY: JANUARY 17, 2014 D O C T O R S A C A D E M YLETTER OF RECOMMENDATION # 1To Evaluator: The letter of recommendation is a valued component of the admission process. Please provide your evaluation of the candidate’s abilities. To the applicant and evaluator: It is understood that this letter of recommendation will be maintained in confidence by UCSF Fresno Latino Center for Medical Education and Research and will be used as one factor in considering admission to the Doctors Academy. In accordance with the Family Education Rights and Privacy Act of 1977, and the related policies and regulations, it is also understood that upon request, this letter will be made available to the applicant for examination.
_____ I do recommend this student. _____ I do not recommend this student. Evaluator’s Name: __________________________________________________________________________________ (Please Print) Title/Position: ____________________________________________________ Phone Number: _____________________ School: __________________________________________________________________________________________ Signature: ____________________________________________________________________ Date: _______________ Please place this letter of recommendation in a sealed envelope and give to the student to submit with application. Questions? Please contact the DA school site: Selma High School, Principal, Mark Babiarz @ 898-6550 or email: MBabiarz@Selma.k12.ca.us Student’s Name: _______________________________ (Must be from a Math, Science or English Teacher) DUE BY: JANUARY 17, 2014 D O C T O R S A C A D E M YLETTER OF RECOMMENDATION # 2To Evaluator: The letter of recommendation is a valued component of the admission process. Please provide your evaluation of the candidate’s abilities. To the applicant and evaluator: It is understood that this letter of recommendation will be maintained in confidence by UCSF Fresno Latino Center for Medical Education and Research and will be used as one factor in considering admission to the Doctors Academy. In accordance with the Family Education Rights and Privacy Act of 1977, and the related policies and regulations, it is also understood that upon request, this letter will be made available to the applicant for examination.
_____ I do recommend this student. _____ I do not recommend this student. Evaluator’s Name: __________________________________________________________________________________ (Please Print) Title/Position: ____________________________________________________ Phone Number: _____________________ School: __________________________________________________________________________________________ Signature: ____________________________________________________________________ Date: _______________ Please place this letter of recommendation in a sealed envelope and give to the student to submit with application. Questions? Please contact the DA school site: Selma High School, Principal, Mark Babiarz @ 898-6550 or email: MBabiarz@Selma.k12.ca.us DOCTORS ACADEMY APPLICATION PROCESS DOCTORS ACADEMY APPLICATION CHECK LIST: Complete and review that your application is typed or printed legibly in ink, and includes the following items: Student and Parent Information (include parent and student signatures) Student Social Security number Personal Statement & Health Disparity Essay 7TH & 8th grade (1st semester report card) transcripts Two Letters of Recommendation in sealed envelope MAILING INFORMATION: MAIL COMPLETE APPLICATION BY FRIDAY, JANUARY 17, 2014 Only complete applications will be reviewed. See checklist above for what makes a complete application. Complete Application MUST be sent to: Abraham Lincoln Middle School Attn: Megan Borboa 1239 Nelson Blvd. Selma, CA. 93662 IMPORTANT TIMELINES: February 2014- Interviews for finalists March 2014- Acceptance Notices Program Administrators:Selma High School – Selma, CaliforniaMark Babiarz, Principal (559) 898-6550 mbabiarz@Selma.k12.ca.us Luis Collazo (559) 898-6550 lcollazo@Selma.k12.ca.us UCSF Fresno Latino Center for Medical Education and ResearchKatherine A. Flores, MD, Director (559) 241-7670 kflores@fresno.ucsf.edu Bertha A. Dominguez, Education Director (559) 241-7670 bdominguez@fresno.ucsf.edu 
SELMA HIGH SCHOOL DOCTORS ACADEMY COURSE PROJECTION SHEET
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