Health Equity & Leadership Institute Application 2013-14

 
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1. Please complete the following.
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2. Where were you born and raised?
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3. How did you hear about program?
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4. What is your race? Mark one or more.
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5. What is your ethnicity?
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6. Which of the following categories best describes your employment status?
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7. Start date of enrollment at current institution.
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8. What is your current enrollment status?
9. What is your GPA?
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10. Describe your educational AND career goals.
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11. Describe your interest in the Health Equity and Leadership Institute. What do you hope to gain from participating in this program?
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12. Describe your greatest strengths AND weaknesses.
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13. List any extracurricular or volunteer activities that you are involved in. This includes clubs, organizations, sports, etc. Also, include any leadership positions you hold.
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14. If selected as a participant, will you be able to fully commit to the program? Required dates and times are:

- 2014 In-person Sessions: January 10, February 7, March 7, April 4 (9am-5pm)
- 2014 Webinars: January 23, February 20, March 20, April 24 (3pm-4pm)
- Promotion Day and Closing Luncheon: May 9, 2014 from 10am – 2pm

* We understand things may come up and that it may be necessary to miss. No more than one excused absence will be allowed.

** Participants are expected to comply with all guidelines and policies of the program and of the University of Mississippi Medical Center. Failure to do so will result in dismissal of the program.

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15. Certify that all of your responses are true and complete to the best of your knowledge by typing your complete name in the text box below.
To complete your application, please send the following documents below to mklein@umc.edu.
a. Resume
b. Headshot (.jpg format)
c. One Letter of Recommendation (can be from an advisor, instructor, or community leader)
d. Unofficial Transcript

All application materials must be submitted by Friday, November 30, 2013.
For more information, please contact Dr. Juanyce Taylor, Program Director, at 601.815.1150.
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