Appendix E
Information Sheet for Prospective Health Professions Students
Name _________________________________ Major ______________________
Preferred Name _________________________ Advisor _____________________
Class of _____________________
Address
Dorm ___________________________________________
Telephone _______________________________________
Home Address ____________________________________
________________________________________________
Home Telephone __________________________________
Father __________________________________________
Occupation _______________________________________
Mother __________________________________________
Occupation _______________________________________
First Year Sophomore Junior Senior
GPA (optional) ____________ ___________ ____________ ___________
Hobbies _____________________________________________________________________
____________________________________________________________________________
Summer jobs ________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Jobs during the academic year (number of hours during the week) ____________________________________________________________________________
____________________________________________________________________________
Goal – Dentistry, PT, Pharmacy, etc
_____________________________
Schools you would like to attend:
___________________________
___________________________
___________________________
___________________________
REQUIREMENTS
1. Required Courses (semester taken or semester intended to take)
a. Math ____________ ____________ ____________ ____________
b. Chem ____________ ____________ ___________ ____________
c. Physics ____________ ___________
d. Biology____________ ___________ ____________ ____________
____________ ____________ ____________ ___________
e. Other ____________ ___________ ____________ ____________
f. Other ____________ ____________ ____________ ____________
2. Recommended courses ____________ ____________ ____________ ____________
3. DAT/GRE/PCAT/etc.
a. Date taken __________________________________ Scores ______ ______ ______
b. Retake _____________________________________ Scores ______ ______ ______
4. Date application was submitted _________________________________
5. HPC interview (date) _________________________________________
EXPERIENCES
1. Hospital or clinical experiences
2. Service experiences
3. Study abroad
4. Research
5. Extracurricular Activities
6. Leadership
7. Honors
