Application for MUSOM Summer Academy
June 11-15, 2018
Application deadline 4/13/18

Name:   * Name

Home Mailing Address
Address 1:  * Home Address 1
Address 2:
City:  * Home City
County:  * Home County
State:  * Home State
Zip:  * Home Zip

Are you a resident of West Virginia for college attendance purposes? Yes No  * Residency
(applicants must be either a US citizen or have permanent residence status, and must be a resident of West Virginia both at the time the application is submitted and at the time the academy begins - proof of citizenship and state residency is required)

College Mailing Address
College Name:  * College Name
Address 1:  * College Address 1
Address 2:
City:  * College City
State:  * College State
Zip:  * College Zip

Phone:  * Phone
Email Address:  * Email
Best Method/Time To Reach You:  * Best Method /Time to be reached

College Major/Minor:  * College Major/Minor

The following questions are for purposes of reporting only and will not be a factor in the application decision process:

Age:  * Age
Gender: Male Female  * Gender
Race/Ethnicity:  * Race/Ethnicity
Do you consider yourself economically disadvantaged? Yes No  * Economically Disadvantaged?

Please list all colleges attended and dates of attendance, beginning with college currently attending: * List of Colleges Attended

Number of total earned college hours:  * Total College Hours
Number of college hours excluding CLEP and AP credit:  * Total College Hours (Excluding CLEP/AP)
Current college GPA at time of application:  * GPA
Highest composite ACT/SAT score:  * ACT/SAT

Please list five extracurricular activities in which you have been involved in the last three years: (club membership, volunteering, hobbies, etc) * Extracurricular Activities

Are you in good academic standing at all colleges attended?  Yes No  * Good Academic Standing
If answer is no, please explain.

Have you ever had a college disciplinary action against you? Yes No  * Disciplinary Actions
If answer is yes, please explain.

Have you ever been convicted of a felony? (Conviction only, not arrests)  Yes No  * Felony

The summer academy runs June 11 through noon on June 15. Attendance at all academy activities is required. There will be activities from the morning into the evening hours each day. Are you available to devote your time to the academy exclusively for the week of June 11-15? Yes No  * Availability

This is a residential academy. Housing will be provided in a residence hall at no cost to the participants. We strongly encourage you to take advantage of this housing, as it will enhance your academy experience.

Please explain why you are interested in medicine as a career, and any activities related to medicine you have pursued in high school and/or college. (limit 500 words) * Explain Interest

PLEASE NOTE: There is no cost to the participants for academy activities. Lodging and food are provided for by the MU JCESOM. However, you would be expected to provide your own linens and your own personal toiletries during the academy. Also, transportation to and from the academy will not be provided, and is the responsibility of the participant.

IMPORTANT: PLEASE SUBMIT THREE COMPLETED RECOMMENDATION FORMS PRIOR TO THE APPLICATION DEADLINE OF APRIL 13, 2018. At least one of these references must be from a professor whom you have had in a college class. The Recommendation Form (pdf) is available for download at: http://crh.marshall.edu/. Please read the instructions carefully. Your application will not be complete until all three Recommendation Forms are received. The forms must be signed and mailed to:

Marshall Medical Center
1600 Medical Center Drive
Suite 1400
Huntington, WV 25701
ATTN: Jennifer Plymale, Academy Director

In addition, an official college transcript from all colleges attended as well as proof of ACT/SAT score must be received at the above address by April 13, 2018 for the application to be considered complete.

NOTE - The application process is open to all. Women, minorities and those from groups that are underrepresented in medicine are especially encouraged to apply.

By submitting this application, I hereby certify that all my answers are true and accurate to the best of my ability.  I hereby certify that I have read and understand the informationa s presented in this application and I agree if accepted, to abide by the rules of the Academy.  I understand that the academy will be governed by an honor code that requires honesty, integrity, and non-discrimination in my interactions with others, and that a breach of this code could result in expulsion from the Academy.

Questions?
Please contact Amber Vance at elkins34@marshall.edu