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Application instructions

HCESSS common application

VCU Acceleration and Alliance programs require two letters of recommendation and official transcripts from each college attended in order to complete the application process.

Mail all supplemental materials including application fee to:
HCE/SSS Pipeline Programs
1000 E. Marshall St.,
Room 203-b
P.O. Box 980124
Richmond, Virginia 23298

Summer Enrichment Program Application

Please select each program that interests you:

Health Educational Research Opportunities - HERO (sophomores through seniors, post baccalaureate, first-year professional students)
Project HELP: Gear-Up program (grade 8 only)
Summer Enrichment Day Camp (grades 4, 5, 6)
VCU Acceleration Program (Accepted incoming VCU freshmen; $50 non-refundable application fee.)
VCU Alliance Research Program (current college sophomores and juniors)
VCU RAMp’s (dental program-college juniors and seniors only)

Please be assured that any information you give to us will not be sold or passed along to a third party (see VCU’s privacy statement.)

Applicant information

First name, middle initial:
Last name:
Suffix:
Preferred name (nickname):
Current street address:
Mailing address (if different from above):
City:
ZIP:
Country:
Legal state residence:
Date of birth:		(e.g. mm/dd/yyyy)
Age:
E-mail address:
Primary phone:
Cell phone:
Alternate phone:
MySpace/Facebook address:

How did you hear about our program?

HCE Web site
Program brochure/flyer
Internet search
Former participant
Other (please list)

How would you describe your current neighborhood?

Urban
Suburb
Rural
Reservation
Islanders
Other:

Family/parent information (Required for ALL applicants)

Parent/guardian name:
Parent/guardian name:
Street address:
City:
State:
ZIP:
Home telephone:
Work/cell telephone:
E-mail:
Highest level of education parent has completed:
Highest level of education parent has completed:

Number of brothers:		Ages:		Grade Level as of Sept. 1, 2008
Number of sisters:		Ages:		Grade Level as of Sept. 1, 2008

Are there any family circumstances, health or special problems which may be useful for us to know in evaluation of your application?

Demographic information
The following fields are required.

Citizenship: United States Citizen or Permanent Resident?

Yes
No

If not U.S., Visa type:
Expiration date:

Ethnicity (Select only one category)

Hispanic or Latino (Select subgroup(s) below)

     Mexican
   Cuban
     Puerto Rican
     South or Central American

Not Hispanic or Latino

Race (Select all that apply)

American Indian or Alaska Native
Asian (List subgroup):
Black/African American
Native Hawaiian or Other Pacific Islander
White
Other:

Total family income:

Less than $10,000 annually
Between $10,000 and $20,000 annually
Between $20,000 and $30,000 annually
Between $30,000 and $40,000 annually
Between $40,000 and $50,000 annually
Between $50,000 and $60,000 annually
Between $60,000 and $70,000 annually
More than $70,000 annually

Have you recieved or qualified for any of the following (check all that apply):

Health Professions Student Loans (HPSL)
Loans for Disadvantaged Student Program
Scholarships from the U.S. Department of Health and Human Services under the Scholarship for Inviduals with Exceptional Financial Need
Pell Grant

Disadvantage Status: Do you consider yourself to be economically, educationally, or socially disadvantaged?

Yes
No

If yes, please explain in 250 words for less:

Personal Statement

Required for VCU Acceleration, VCU Alliance and VCU RAMp's students: Please explain why you are interested in this program and what you are looking, or anticipate, that you will get out of this program.

Parents of Summer Enrichment Day Camp: Please briefly explain what you are looking for your child to gain from this experience.

Please rank on a scale of 1-5 your choice of VCU Health Sciences in your college decision (1 = top choice; 5 = unlikely).

1 2 3 4 5

Health Career interest (Select all that apply)

Clinical Laboratory Sciences
Dentistry
Health Administration
Medicine (M.D.)
Nursing
Occupational Therapy
Pharmacy
Physical Therapy
Radiation Sciences
Research Careers
Other

Education (begin with most recent)

Grade as of Sept. 1, 2008:

Institution/ school	Dates attended	Major (If applicable)	Graduation date	GPA and Scale (e.g. 4.0)

Academic honors and awards recieved:

Please list any volunteeer activities, school organizations, work experience or other activities:

Organization	Dates	Responsibilities	Supervisor/leader contact information

Test scores
SAT Verbal	SAT Math	SAT Composite	ACT total score

References

Name:		Name:
Phone number:		Phone number:
Relationship to yourself:		Relationship to yourself:

Virginia Commonwealth University
Office of the Vice President for Health Sciences
Division of Heath Careers / Education and Special Services for Students
Contact us
Updated: 07/02/2008
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