MEDICINA ACADEMY APPRENTICE PROGRAM
2017-2018 Application for Admission * Solicitud de Admisión 2017-2018
Extended Deadline: June 9, 2017
Fecha Límite Extendida: 9 de junio del 2017
Completed packets can be done online or sent by mail, fax or email/
Solicitudes completas pueden entregarse en línea o enviarse por correo, fax o correo electrónico
By mail/ Por correo:
c/o Medicina Academy Apprentice Program
Hispanic Center of Excellence in Medicine (MC 591)
808 S. Wood St., 990 CME
Chicago, IL 60612-7333
By fax/ Por fax:
c/o Medicina Academy at 312-996-9922
Email/ Correo electrónico: [email protected]
For more information/ Para más información:
Melinda Monge or Kendy Oláguez
Phone: (312) 355-2529 * email: [email protected]
Medicina Academy Apprentice Program 2017-2018
cademy: Admissions Application 2010-2011
Medicina Academy/ Academia de Medicina
Developed in 2009 as part of the Hispanic Center of Excellence’s medical pipeline initiative, the Medicina Academy Apprentice Program
(MAAP) is a pre-medical program aimed to initiate an educational pathway into medical school by investing in the preparation of high
school students aspiring to become physicians. Apprentices take part in medical courses & lab sessions; higher education courses; and
inter/intrapersonal activities; and career development sessions twice a month on Saturdays from September to May.
Desarrollado en 2009 como parte de las iniciativas de desarrollo médico del Hispanic Center of Excellence in Medicine (Centro Hispano de
Excelencia en Medicina), Medicina Academy Apprentice Program (MAAP) es un programa de aprendizaje para estudiantes en la secundaria
aspirando a ser médicos. Los aprendices toman parte en clases y sesiones de laboratorios en medicina; cursos de educación superior; y
actividades de desarrollo inter/intrapersonal; y sesiones de carreras dos sábados al mes entre septiembre a mayo.
REQUIREMENTS/REQUISITOS
Program Commitment and Expectations
 Participants must actively engage in bimonthly Saturday
seminars and all activities;
 Participants must submit all assignments electronically
unless otherwise specified;
 Medicina Apprentices MUST take part in all aspects of the
program;
 Student MUST maintain an unweighted GPA of 3.00/4.0 to
remain in good academic standing and for promotion
purposes in the program.
Program Eligibility
 Must be a current 8th, 9th, 10th or 11th grader at time of
application (Needs to be matriculated in high school and in
9th, 10th, 11th or 12th grade by Fall 2017);
 Hispanic/Latino origin or interested in medical careers that
serve the Latino community;
 Know at minimum conversational Spanish;
 Submit all completed items listed under the Checklist for
Admissions Packet.
Checklist for Admissions Packet
□ Admissions Application for MAAP
□ Personal Statement
□ Recommendation letter & form (should come from teacher
or counselor)
□ 8th graders: Copy of current grade report (Note: grades will
be recalculated using the standard 4.0 grading scale and
students must have an unweighted GPA of 3.00/4.0 to
qualify for the program)
□ 9th, 10th , and 11th graders: Copy of unofficial transcript
Compromiso y Expectativas del Programa
 Los participantes deben participar en los talleres bimensuales en
los sábados y todas las actividades;
 Los participantes deben entregar todas las tareas
electrónicamente a menos de que sea especificado de otra manera
 Se requiere que los estudiantes participen en todos los aspectos
del programa;
 Se requiere que los estudiantes mantengan un promedio
académico de 3.00/4.0 para estar académicamente acreditados y
por propósitos de promoción en el programa.
Elegibilidad para el Programa
 Debe ser un/a estudiante en 8º, 9º, 10º, o 11º grado durante el
tiempo de solicitud (Necesita estar matriculado en la secundaria y
en 9º, 10º , 11º, o 12º grado en el otoño del 2017);
 Ser de origen Hispano/Latino o interesado en carreras médicas
que trabajan con la comunidad Latina;
 Por lo menos mantener una conversación en español;
 Entregar por completo todo el contenido en la Lista del Paquete
de Admisión.
Lista del paquete de admisión
□ Solicitud de admisión para MAAP
□ Composición Personal
□ El formulario de recomendación y carta (deben venir de un
maestro o consejero)
□ Estudiantes en 8º grado: Copia de calificaciones actuales de 8º
grado (Importante: calificaciones serán recalculadas usando la escala
académica de 4.0 y los estudiantes deben tener un promedio académico de
3.0/4.0 para calificar en este programa)
□ Estudiantes en 9º, 10 º, y 11º grado: Una copia del reporte
académico (transcript)
IMPORTANT/IMPORTANTE


Applications must be received by Friday, June 9, 2017
Las solicitudes deben ser recibidas el viernes, 9 de junio del 2017
After the Review of Applications round, the second round will consist of an interview (by invitation only)
Después de la selección de solicitudes la segunda ronda consistirá de una entrevista (por invitación solamente)
For more information/Para más información: Melinda Monge or Kendy Olaguez
Phone: (312) 355-2529 * email: [email protected]
Note: Applications that are incomplete or received after the deadline will not be considered./No se consideraran solitudes incompletas o recibidas despues de la fecha límite.
2017-2018 Medicina Application_
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Medicina Academy Apprentice Program 2017-2018
cademy: Admissions Application 2010-2011
Student Information/ Información Estudiantil
First Name/ Nombre
Middle Name/ Segundo Nombre
Last Name/ Apellido
Date of Birth/Fecha de
Nacimiento:
/
Address/ Dirección
City/ Ciudad
Home Phone #/No. Telefónico del domicilio: (
)
How did you hear about MAAP?
What is your current status?/
¿Cuál es tu estatus migratorio?
F
ZIP Code/ Código Postal
Cell Phone #/ No. de celular: (
Email Address/Correo electrónico:
M
/
State/ Estado
)
Sex/ Sexo
□U.S. Citizen/
Rate your Spanish Language Proficiency (Select one):
None
Limited Basic
Moderate
Conversational
Fluent
□Permanent Resident □Other/ Otro
Ciudadano Estaudonidense
Residente Permanente
Current School/ Escuela:
Grade/Grado:
Current GPA/Promedio Académico:
In sections 1-3 check all that apply for the applicant (For statistical purpose only)/En secciones 1-3 indique todo lo que aplique al solicitante (Sólo con fines estadísticos)
Student’s Race/Ethnicity/Nationality; check all that apply ------ Raza/Etnicidad/Nacionalidad; Indique todo los que apliquen
(For statistical purpose only)
(1) Race/Raza
 American Indian or Alaska Native/
Amerindio o Nativo de Alaska
 Asian/ Asiático
 Black or African-American/ Negro o
Afroamericano
 Native Hawaiian or other Pacific
Islander/ Nativo de Hawaii u Otro Isleños
del Pacífico
 White/ Blanco
(Sólo con fines estadísticos)
(2) Ethnicity/Etnicidad
 Hispanic/Hispano, Latino,
Chicano
(3) Nacionality/Nacionalidad
If you previously selected
 Colombian/ Colombiana
Latino/Hispanic/ Chicano please select  Cuban/ Cubana
from the following Nationalities (check  Ecuadorian/ Ecuatoriana
all that apply)…
 Guatemalan/ Guatemalteca
 Non-Hispanic/No Hispano,
Si previamente seleccionó
Latino o Chicano
Latino/Hispano/Chicano, por favor,
seleccione de las siguientes
nacionalidades (Marque todas las que
apliquen)…
 Mexican/ Mexicana
 Puerto Rican/ Puertorriqueña
 Salvadorian/ Salvadoreña
 Other/ Otra_____________
List all science and math courses you have taken including dates/ Indique todos los cursos de ciencias y matemáticas que ha tomado incluyendo fechas
____________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
Which area of the medical/health field interests you the most?/¿Cuál es la rama de la medicina o campo de salud que más le interesa?
1._______________________________________________________
4.___________________________________________________________
2. _______________________________________________________
5.___________________________________________________________
3. _______________________________________________________
6.___________________________________________________________
List your community and/or extra-curricular involvement /Indique todas las actividades escolares y comunitarias en las que usted ha participado
1._______________________________________________________
4.___________________________________________________________
2. _______________________________________________________
5.___________________________________________________________
3. _______________________________________________________
6.___________________________________________________________
Please list any honor or awards/certificates received /Indique todos los honores o premios que ha obtenido
1._______________________________________________________
3.___________________________________________________________
2. _______________________________________________________
4.___________________________________________________________
Are you currently a participant in the HCOE Medicina AcademyApprentice Program at UIC?
¿Actualmente participa en nuestro programa Medicina Academy apprentice program en UIC?
Have you previously participated in LaHSEP? / ¿Previamente ha participado en el programa LaHSEP?
□Yes/Sí □□Yes/Si
No
□Yes/Sí
□
No
Cohort/Grupo _________
when/¿cuándo?
□No
T-shirt size/ Talla de camiseta: ______________________
Household Information/ Información del Hogar
Father’s Name/ Nombre del Padre:
 Deceased/
Occiso
Type of employment/ Tipo de empleo:
Mother’s Name/ Nombre de la Madre:
2017-2018 Medicina Application_
Cell Phone #/ No. de celular: (
)
)
Does the applicant live with you? ¿El Applicante vive con usted?
 Deceased/
Occiso
Type of employment/ Tipo de empleo:
Work Phone #/ No. de trabajo: (
Work Phone #/ No. de trabajo: (
Cell Phone #/ No. de celular: (
)
)
Does the applicant live with you? ¿El aplicante vive con usted?
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Medicina Academy Apprentice Program 2017-2018
cademy: Admissions Application 2010-2011
Names & ages of other children/ Nombres y edades de sus otros hijos:
1._______________________________________________________
2. _______________________________________________________
3. _______________________________________________________
4.___________________________________________________________
5.___________________________________________________________
6.___________________________________________________________
Community/ Comunidad en que vive (e.i Pilsen, Humboldt Park, Buck Town…):
Indicate highest level of education you completed/ Indique el nivel más alto de educación que usted completo:
Mother/Madre (guardian/ tutor)
 Elementary education/ Educación Basica: ___________years/años
 Secondary education/ Educación Media: ___________years/años
 Higher Education/ Educación Superior (check/indique):
_____ Some College
_____ AA/AS Degree (Titulo de Asociado)
_____ BA/BS Degree (Bachillerato/ Licenciatura)
_____ Master’s Degree (Maestria)
_____ Doctorate Degree (Doctorado)
Location/ Lugar
_____________
_____________
_____________
_____________
_____________
_____________
_____________
Father/Padre (guardian/ tutor)
Location/Lugar
 Elementary education/ Educación Basica: __________years/años __________
 Secondary education/ Educación Media: ___________years/años __________
 Higher Education/ Educación Superior (check/indique):
_____ Un poco de colegio
__________
_____ AA/AS Degree (Titulo de Asociado)
__________
_____ BA/BS Degree (Bachillerato/ Licenciatura)
__________
_____ Master’s Degree (Maestria)
__________
_____ Doctorate Degree (Doctorado)
__________
__________
___
Location of where education was obtained/Lugar:
Indicate the household income/ Indique el ingreso anual del hogar:
_____Less than $9,999/ Menos de $9,999
_____$10,000-$14,999
_____$15,000-$19,999
_____$20,000-$24,999
_____$25,000-$29,999
_____$30,000-$34,999
_____$35,000-$39,999
_____$40,000-$44,999
_____$45,000-$49,999
_____More than $50,000/Más de $50,000
EMERGENCY INFORMATION/ INFORMACIÓN DE EMERGENCIA
Name/ Nombre :
Cell Phone #/ No. de celular: (
Relationship/Relación:
Work Phone #/ No. de trabajo: (
)
)
Address/ Dirección del tutor legal:
City/ Ciudad
Does your child have a disability?/ ¿Tiene su hija/o una discapacidad?
If so, please explain/ Si respondió que si favor de explicar.
□ NO
State/ Estado
ZIP Code/ Código Postal
□ YES/SI
Do we need to be aware of any medication that your child is taking? / ¿Su hija/o toma algun medicamento del cual tenemos que ser conscientes?
If so, please explain/ Si respondió que si favor de explicar.
□ NO
□ YES/SI
Application Condition/ Condiciones de la Solicitud
I understand that withholding information or giving false information requested on this application may make me/ my child ineligible for
admission to the Medicina Academy Apprentice Program or subject to dismissal if admitted. I have read and understood all instructions
and information on this application and certify that the statements I have made on this application are correct and complete.
By completing and submitting this application to the Hispanic Center of Excellence in Medicine, I also acknowledge that if I/my child is
accepted I/my child will attend and complete MAAP. I understand this experience requires my child to maintain a minimum 3.0
unweighted GPA. As a Medicina Apprentice if my child has below the required 3.00 unweighted GPA during any quarter I realize
academy measures will take place; my child and I will need to speak with an academic dean or director of the program as a result.
Tengo entendido que la retención de información o dar información falsa en esta solicitud puede hacerme o hacer a mi hijo(a) inelegible para la admisión
del programa Medicina Academy Apprentice Program o sujeto a ser despedido si admitido. He leído y entendido todas las instrucciones e información
sobre esta solicitud y certifico que los datos asentados en esta solicitud son los correctos.
Al completar y presentar esta solicitud al Centro Hispano de Excelencia en Medicina (HCOE), reconozco que si mi hijo(a) es aceptado(a) yo/mi hijo
asistiremos y completaremos el programa MAAP. Entiendo esta experiencia obliga a mi hijo(a) mantener un promedio académico de 3.00. Como
Aprendiz de Medicina si mi hijo(a) obtiene menos del promedio académico de 3.00 durante cualquier semestre entiendo qué medidas académicas tendrá
lugar y mi hijo(a) y yo necesitaremos hablar con un decano académico o director(a) del programa como resulto.
Student Signature/ Firma del Estudiante: ________________________________________________
Date/Fecha:________________
Parent or Guardian Signature/ Firma del Padre o Tutor:____________________________________
Date/Fecha:________________
2017-2018 Medicina Application_
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Medicina Academy Apprentice Program 2017-2018
cademy: Admissions Application 2010-2011
Personal Statements
(Please be sure to answer each of the questions thoroughly)
A) Current 8th graders:
Attach a typed personal statement of 600 words minimum answering the following 2 questions:
1. What is your inspiration to become a physician? How would you like to contribute to your community and
what are the qualities needed?
2. How can the Medicina Academy Apprentice Program prepare you to become a physician? What are your
expectations of the Medicina Academy Apprentice Program?
B) Current 9th graders:
Attach a typed personal statement of 600 words minimum answering the following 2 questions:
1.
2.
Discuss how factors such as education environment, social economic status, life experience, and/or family
background have influenced you to pursue a career in medicine.
Describe your interest in the Medicina Academy Apprentice Program.
C) Current 10th graders:
Attach a typed personal statement of 600 words minimum answering the following 2 questions:
1. Tell us about a difficult or challenging situation that you have encountered and how you dealt with it.
2. What barriers do you foresee towards your goals of becoming a physician?
D) Current 11th graders:
Attach a typed personal statement of 600 words minimum answering the following 2 questions:
1. Tell us about an accomplishment or experience that symbolizes your transition from childhood to being a
young adult. How does this accomplishment or experience influence your capacity to advocate for
underserved communities as a future physician?
2. Discuss your strengths and qualifications for the Medicina Academy Apprentice Program. How can the Medicina
Academy Apprentice Program help you achieve your goals of becoming a physician?
2017-2018 Medicina Application_
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Medicina Academy Apprentice Program 2017-2018
cademy: Admissions Application 2010-2011
[PURPOSELY LEFT BLANK]
2017-2018 Medicina Application_
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Medicina Academy Apprentice Program 2017-2018
cademy: Admissions Application 2010-2011
RECOMMENDATION FORM/ FORMULARIO DE RECOMENDACIÓN
DUE DATE: FRIDAY, JUNE 9, 2017
Section 1- To be completed by applicant
Name: _________________________________________
Grade level: _______________________
School: ________________________________________
GPA: ___________________ (if applicable)
Weighted
Unweighted
TO THE APPLICANT:
Under the provisions of the Family Educational Rights and Privacy Act of 1974, and if you are admitted into Medicina Academy
Apprentice Program, you will have access to the information provided in the Recommendation Form unless you have waived such
access. Please sign and date below to inform us of your decision. Your choice will not affect your eligibility for admission.
I hereby waive my rights of access to the
recommendation prepared in response to
this request
I do not waive my rights of access to the
recommendation prepared in response to
this request
OR
_____________________________________
Signature of Applicant
_____________________________________
Date
Signature of Applicant
Date
If this section is not completed, applicant automatically waives his/her right to access.
Section 2- To be completed by recommender
The person named on the top of this form is applying for admission to a high school pre-medical and higher education preparation
program in the Hispanic Center of Excellence, College of Medicine at the University of Illinois at Chicago. You have been selected by
the applicant to submit your comments on his/her qualifications. Use this form to evaluate the applicant and please write an additional
letter on letterhead that provides your insights into the applicant’s academic qualifications, interest in the medical field, and ability to
benefit from this academic enrichment program. Once you complete the recommendation form, place in a sealed envelope along with
the letter of recommendation and your signature across the seal and mail to: KENDY OLAGUEZ. Medicina Academy Apprentice
Program, 808 S. Wood St., Suite 990, Chicago, Illinois 60612. You can also submit a PDF of this form and letterhead with your signature
to Melinda Monge via email: [email protected] or fax: 312-996-9922.
Please rate the following personal characteristics:
Characteristic
Below
Average
Average
Above
Average
Excellent
No
Opinion
Self-Confidence, poise
Judgment, ability to evaluate a problem, common sense, decisiveness
Reliability, punctual, responsible
Maturity, ability to deal with a variety of circumstances
Empathy, compassionate, understanding
Academic potential
Leadership potential, ability to lead and initiate
Interpersonal Relations, ability to work with others and in a team
Oral Expression, communication skills, clarity of expression verbal/written
How long have you known the applicant? ________________
This student ranks ______ in a class of _____
Overall do you recommend the applicant to the Medicina Academy Apprentice Program (MAAP)?
Highly Recommend
Recommend
Do not recommend
Do not have sufficient information to recommend applicant
Recommender signature
______________________ Date ___________________________________
2017-2018 Medicina Application_
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