Uiersit o Haai‘i at Ma¯ oa o A Burs Scool o Meicie Name ...jabsom.hawaii.edu/wp-content/uploads/2019/11/SAMPLE_Imi-Hoola... · Uiersit o Haai‘i at Ma¯ oa o A Burs Scool o Meicie

University of Hawai‘i at Ma noaJohn A. Burns School of Medicine

651 Ilalo Street, MEB • Honolulu, HI 96813Telephone: (808) 692-1030 • Fax: (808) 692-1254

‘Imi Ho‘olaPost-Baccalaureate Program

PERSONAL

INFORMATI

ON

NAME:

_________________________________________________

Current Mailing Address:

_________________________________________________

_________________________________________________

Permanent Mailing Address: (if different from current mailing address)

_________________________________________________

_________________________________________________

Telephone: ______________________________________

E-mail address: __________________________________

Legal Residence:

_________________________________________________

LAST FIRST M.I.

STATE COUNTRY

AMCAS ID #: _______________________________

Date of Birth: ______ / ______ /______ Age: ____

Gender Male Female

Other ________________________________________

Marital Status:

Single Married Divorced

Other ________________________________________

Birthplace:

____________________________________________

Ethnicity (list all):

____________________________________________

____________________________________________

____________________________________________

____________________________________________

STATE COUNTRY

2020-2021 Application

Citizenship: ________________________________

Visa Status (if not U.S. citizen): ________________

Is English your first language? (primary language spoken in the home)?

YES NO

Geographical area you spent the majority of your life from birth to age 18 (street address required): Choose one location only.

______________________________________________________

______________________________________________________

STREET ADDRESS

CITY/TOWN STATE ZIP CODE COUNTRY

See Application Booklet for Printing Instructions.

Nam

e: ____________________________________________________

Late or incomplete applications will not be considered.1

SAMPLE

Name: ____________________________________________________

F A M I L Y

B A C K G R O U N D

* List current or most recent occupation. If retired or deceased, list the last occupation held.

Paternal Grandfather Paternal Grandmother

Maternal Grandfather Maternal Grandmother

Name:

Current Address:

Telephone:

Marital Status:

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

Father Mother

EDUCATION Number Years of schooling: (i.e., 16 years = 12 + 4 college)Highest degree attained: Name of school: (ie: High School, University)

Occupation:*

Duties/Responsibilities:


Occupation:*



Occupation:*


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SAMPLE

Name: ____________________________________________________

E C O N O M I

C

B A C K G R O U N D

Combined Annual Income of Parent(s):(Based on 2018 U.S. income tax return. Please complete whether or not you are self-supporting.)

$28,760 and under $28,761 - $38,920 $38,921 - $49,080 $49,081 - $59,240 $59,241 - $69,400 $69,401 - $79,560 $79,561 - $89,720 $89,721 - $99,880 $99,881 or more

How many people are claimed on 2018 U.S. income taxreturn including yourself (if applicable) and your parent(s)/guardian(s)?_________________________________________________List their relationship to you and their ages. Include yourself if applicable:RELATIONSHIP AGE

Annual Income of Applicant (Combined with Spouse if Applicable):(Based on 2018 U.S. income tax return. Do not complete if you are claimed as a dependent by your parents.)

$28,760 and under $28,761 - $38,920 $38,921 - $49,080 $49,081 - $59,240 $59,241 - $69,400 $69,401 - $79,560 $79,561 - $89,720 $89,721 - $99,880 $99,881 or more

How many people are claimed on 2018 U.S. income taxreturn including you and your spouse?_________________________________________________List their relationship to you and their ages:

RELATIONSHIP AGE

___________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________SPOUSE’S OCCUPATION: _______________________________

Is the combined annual income of your parent(s) or guardian(s) for year 2018 U.S. income tax return below $90,200 (Hawai‘i median income based on U.S. Census Bureau for 4-Person Family)?

YES NO

Have you or members of your immediate family ever used Federal or State assistance programs (e.g., foodstamps, free lunch, welfare)?

YES NO If yes, list year(s) received assistance:

Did you have paid employment prior to age 18?

YES NO

If yes, were you required to contribute to the overall family income (as opposed to working primarily for own discretionary spending)?

YES NO

Have you used need-based scholarship(s) or loan(s) to fund your undergraduate or graduate education?

YES NO

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SAMPLE

Name: ____________________________________________________

E DUCATI

ONAL

B A C K G R O U N D

High School where you received your diploma: Public Charter Private Home School Other

________________________________________________________________________________________________________________

High School attended, if different from graduated from: Public Charter Private Home School Other

________________________________________________________________________________________________________________

Were your science courses/laboratory experiences sufficient to prepare you for college? YES NO

Did you utilize science courses/lab experiences to prepare you for college? YES NO

Did your high school provide you with sufficient counseling that encouraged you to pursue a bachelor’s degree? YES NO

Undergraduate, Graduate and Professional Schools Attended: All undergraduate colleges attended (list most recent first):

___________________________ ____________ _____________ ____________ _______ _________________________________ ____________ _____________ ____________ _______ _________________________________ ____________ _____________ ____________ _______ ______

INSTITUTION CITY/STATE DATES ATTENDED MAJOR DEGREE EXPECTED

DATEGRANTED/

Graduate or Professional School(s) attended:

___________________________ ____________ _____________ ____________ _______ _________________________________ ____________ _____________ ____________ _______ ______

Have you ever been placed on probation, suspension, or dismissal by a college or university? YES NO

If yes, provide complete details below, including date(s) of action(s). Attach additional sheet if necessary.________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

Do you have a physician or healthcare role model/mentor? YES NO

Did you have a support system while attending college? YES NO

HIGH SCHOOL NAME

HIGH SCHOOL NAME

CITY

CITY

STATE

STATE

YEAR GRADUATED

YEAR(S) ATTENDED

Did you apply to the ‘Imi Ho‘ola Program previously? YES NO If yes, what year(s)?

Did you apply to JABSOM previously? YES NO If yes, what year(s)?

INSTITUTION CITY/STATE DATES ATTENDED MAJOR DEGREE EXPECTED

DATEGRANTED/

4

SAMPLE

Name: ____________________________________________________

SOCIAL

BACKGROUND

List Health Career Opportunity Programs (HCOP) and other disadvantaged programs you have participated in:

Organization Name: _____________________________________ Dates: __________________________________________City/State/Country: ______________________________________________________________________________________Experience Name: ______________________________________________________________________________________Experience Description: ______________________________________________________________________________________

______________________________________________________________________________________

Organization Name: _____________________________________ Dates: __________________________________________City/State/Country: ______________________________________________________________________________________Experience Name: ______________________________________________________________________________________Experience Description: ______________________________________________________________________________________

______________________________________________________________________________________

List College Honors/Awards:

__________________________ _________________________ _______________________________

__________________________ _________________________ _______________________________

__________________________ _________________________ _______________________________

NAME OF AWARD DATE RECEIVED DESCRIPTION

List Research Experiences:

Organization Name: ______________________________________________ From: Month: ____________ Year: _________City/State/Country: ______________________________________________ To: Month: ______________ Year: _________Experience Name: ______________________________________________ Total Hours: ____________________________Experience Description: ______________________________________________________________________________________

______________________________________________________________________________________


______________________________________________________________________________________


______________________________________________________________________________________

5

SAMPLE

E X T R A C U R R I

C U L A R

A. Extracurricular College Activities (list most recent first):


______________________________________________________________________________________


______________________________________________________________________________________


______________________________________________________________________________________

B. Volunteer Health Experience, Public Service, or Community Activities (list most recent first):


______________________________________________________________________________________


______________________________________________________________________________________


______________________________________________________________________________________

C. Employment (list most recent first):


______________________________________________________________________________________


______________________________________________________________________________________

6

SAMPLE

Name: ____________________________________________________

A. Describe why you want to pursue a career in medicine. What key experiences have influenced this decision?

P E R S O N A L

S T A T E M E N T

3000 character maximum, single space 12 pt font (spaces are counted as characters)

7

SAMPLE

Name: ____________________________________________________

B. Describe any family or personal circumstances (e.g. hardships) that will be useful in reviewing your application.

P E R S O N A L

S T A T E M E N T

1500 character maximum per essay, single space 12 pt font (spaces are counted as characters)

C. Describe how you have been able to overcome any personal hardship or adversity that you have faced.

8

SAMPLE

Name: ____________________________________________________

D. 1) Describe your past and current demonstrated commitment to serve in Hawai‘i and/or the Pacific Region.

P E R S O N A L

S T A T E M E N T

Please answer each question separately. 750 character maximum per essay, single space, 12 pt font (spaces are counted as characters)

2) What is your most significant experience in the areas of community service, volunteer and/or leadership and why did you choose this experience?

3) How do you envision yourself serving in areas of need as a future physician?

4) Following your residency training, what types of patients will you serve and where do you wish to practice?

9

SAMPLE

Name: ____________________________________________________

Date of most recent MCAT: ____________________

List Medical Schools that you are currently applying to:

______________________________________________________ ___________________________________________________

______________________________________________________ ___________________________________________________

______________________________________________________ ___________________________________________________

______________________________________________________ ___________________________________________________

Recommender: _______________________________________ Title: ________________________________________________

Recommender: _______________________________________ Title: ________________________________________________

MEDICAL SCHOOL MEDICAL SCHOOL

Two letters of recommendation are required. At least one of the letters should be from a professor or advisor that can attest to applicant’s academic ability. (Maximum two letters of recommendations will be accepted.)

How did you hear about the ‘Imi Ho‘ola Program?______________________________________________________________

CertificationI certify that the information submitted in this application is complete and correct to the best of my knowledge. I understandthat any misrepresentation, falsification, or failure to supply required information in connection with this application may resultin the rejection of my application. I agree to notify the ‘Imi Ho‘ōla Post-Baccalaureate Program of any changes thatarise during the application process.

_________________________________________________________________ _________________________________________SIGNATURE DATE

* Please mail the original form directly to the ‘Imi Ho‘ola Post-Baccalaureate Program by the postmark deadline ofNovember 1, 2019 and keep a copy for your personal records.

Late or incomplete applications will not be considered.

John A. Burns School of Medicine

10

SAMPLE

APPLI

CANT

NOTES

APPLI

CANT

NOTESSAMPLE

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Uiersit o Haai‘i at Ma¯ oa o A Burs Scool o Meicie Name ...jabsom.hawaii.edu/wp-content/uploads/2019/11/SAMPLE_Imi-Hoola... · Uiersit o Haai‘i at Ma¯ oa o A Burs Scool o Meicie

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