Information Sheet for Prospective Health Professions Students
Click here for a printable version of this form.
Name ____________________________________________ Major ______________________
Preferred Name _____________________________________ Advisor _____________________
Address - Dorm ____________________________________ Class of _____________________
Telephone _______________________________________
Home Address ____________________________________
____________________________________
Home Telephone __________________________________
Father _____________________________________________
Occupation ______________________________________
Mother _____________________________________________
Occupation ______________________________________
First Yr. 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. ____________ ___________
____________ ____________
f. ____________ ____________ ____________ ____________
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
