Southern California Regional Dentistry Post-Baccalaureate Program ucla & Loma Linda, Schools of Dentistry



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Deadline: April 29, 2016



Southern California Regional Dentistry Post-Baccalaureate Program

UCLA & Loma Linda, Schools of Dentistry

2016

INSTRUCTIONS: Type or print (attach additional sheets if necessary).


  1. PERSONAL DATA (Personal data, including your gender and ethnicity, will remain confidential and will only be used to satisfy reporting requirements set by program funding agencies.)







Last Name First Name Middle Name










Current Address Apt. #



City State Zip Code





Permanent Address Apt. #



City State Zip Code






Current Telephone: (____)




Permanent Telephone: (____)







E-mail Address:




Birthplace:
















Birth Date:




Gender:
















SS#:




Marital Status:







Your Health Insurance Carrier:



Policy #:








  1. FAMILY DATA (Name and address of parent(s) or guardian)







Last Name First Name Middle Name Relationship




Last Name First Name Middle Name Relationship







Street Address Apt. #







City State Zip Code


Telephone(s) (____) _______________________ or (____)_______________________



In case of emergency contact:





Last Name First Name Middle Name
Telephone(s) (_______) _______________________________ or (_______)_______________________________





EDUCATIONAL BACKGROUND

(Highest level completed)



OCCUPATION

Father:









Mother:








Please list all siblings; include name, age, education and occupation:


Brothers:











Sisters:











Ethnicity (Please check all that apply):

African American ___



Japanese/Japanese American ___

Pacific Islander ___



American Indian/Alaskan Native ___

Korean/Korean American ___

Vietnamese/Vietnamese American ___

Cambodian ___

Chinese/Chinese American ___

East Indian/Pakistani ___

Filipino/Filipino American ___



Laotian ___

Mexican/Mexican American/Chicano ___

Other Spanish American/Latino ___



White/Caucasian ___

White/Middle Eastern ___

Other - Please Indicate

______________________________






Applicant’s first language:










Applicant’s second language:










Primary language spoken at home:







  1. EDUCATIONAL DATA (List all high schools, colleges, graduate and professional schools attended in chronological order)





Institution


Location

Dates of Attendance

(month & year)




Student I.D.


Major

Degree Granted

(or expected) With Date


















































































































Cumulative Undergraduate Overall GPA




Cumulative Undergraduate Science GPA
















Cumulative Graduate Overall GPA




Cumulative Graduate Science GPA



Please list any additional and/or current course work not listed on your transcripts:



Course

College/University

Grade

Units












































Please list any scholastic honors or awards you may have received:











If your education has not been continuous or if you have been out of school for more than 1 year, please explain:














DAT: Total number of attempts, if any: __________
Scores - First Attempt: Acad. Ave. ________ PA ________ QR. ________ RC. ________ Bio. ________G-Chem. ________

O-Chem. ________ Total Science ________ Date DAT taken: ___________________



Scores - Second Attempt: Acad. Ave. ________ PA ________ QR. ________ RC. ________ Bio. ________G-Chem. ________

O-Chem. ________ Total Science ________ Date DAT taken: ___________________



Or: Date planning to take (or re-take) the DAT _____________________

A DAT attempt is NOT a requirement for acceptance to the UCLA Dental Post-Baccalaureate Program.
When do you expect to submit your application to dental school?





If you have previously applied to dental school, medical school or any other professional school, fill in the following:




Dental, Medical or Other Schools Applied To:

Secondary Granted

Interview Granted


Wait List


Hold

Date of Acceptance

Date of Rejection
































































































































































































































































  1. EXTRACURRICULAR ACTIVITIES

(Please list the most significant non-academic activities in which you have participated; including research, volunteer and paid work positions)



Job Title


Dates (from/to)

Number. of Hours

( per week)




Location


Duties
























































































































Please list your participation in student and community organizations, noting the dates and years of participation and any positions held:





Organization


Location

Dates of Participation


Position Held

(if any)



Description of Activities









































































































Please list all pre-dental or premedical enrichment programs, including post-baccalaureate programs, in which you have participated:




Name

Location

Dates































































Are you currently applying to any other post-baccalaureate or re-application program(s)? ______Yes ______No

If yes, please list:





































How did you hear about the Southern California Regional Post-Baccalaureate Program?

























  1. SOCIOECONOMIC BACKGROUND

Please answer the following short essay questions, provide as much detail as possible and explain the background/circumstances you come from (feel free to write your answer in the space provided, or attach them to a separate sheet of paper):


a.

Describe the geographic location and community of your home during your childhood, including socioeconomic conditions, housing, rural, urban, foreign country, and other representation. Do you

come from a historically disadvantaged community/neighborhood with limited educational and

supportive resources? (i.e., neighborhoods with a high percentage of high school dropouts, where

few go on to attend college; neighborhoods with high unemployment and associated socioeconomic problems)











b.

Do you come from a region/community where there is a shortage of medical and dental care, or where most of the care is provided by city, county, state, or federal clinics and hospitals? (i.e., rural community, inner-city community) - If yes, please explain.








c.

Describe any specific difficulties in your life. Include how you dealt with them and their influence upon your growth.








d.

How are you financing your education? (attach copy(s) of financial aid award if pertinent)









e.

What was the number of people in your household during your life, from birth to age 18? Did you have any special responsibilities?









f.

Do you provide support to anyone other than yourself? If yes, please explain:









g.

Are you the first (or one of the first) of your family members to attend college, or to apply to professional or graduate school









h.

Have you faced hardships that interfered with your educational pursuits? If so, please describe.








  1. STATEMENT OF INTENT

Please attach a typed 2 – 3 page concise Statement of Intent addressing the following:




Present academic status



Disadvantaged or underserved status



What you expect to gain from participation in the Post-Baccalaureate Program



Areas you would like assistance in improving



Your future career aspirations




  1. PLEASE SUBMIT THE FOLLOWING:






DAT scores (if you have taken the DAT)



All official college transcripts




  1. LETTERS OF RECOMMENDATION

Please submit three official letters of recommendation. The letters should be from individuals who can attest to your service to the community and your commitment to helping underserved populations. At least one letter should be from a recent teacher or faculty member. Letters submitted for previous AADSAS Dental School applications will be accepted, but the letters author or letter service will need to resend the recommendation to the program directly.




  1. APPLICATION PERIOD

Walk-in application submissions will be accepted from January 29th to April 29th, 5:00pm PST. All mailed application materials must be post-marked by Saturday, April 30th to be processed (included in your application). Materials received after the dates listed above will not be processed. Incomplete applications will not be considered for review.





  1. STATEMENT OF AUTHENTICITY AND PARTICIPATION

I certify that the above information is true and correct. I agree to provide, if requested, any official or unofficial documentation necessary to verify this information. I understand that false statements or misrepresentations on this form may result in cancellation of admission to the Post-Baccalaureate Program.


If accepted to the Post-Baccalaureate Program and I accept, I will participate fully in this Program and abide by all the rules and regulations as stipulated by the Director. This includes my attendance at classes, workshops, special presentations, tutorials and meetings during the stated period of the Program.
It is my full intention to use my knowledge and skills to serve the underserved upon my graduation from dental school.

Applicant’s Signature: ______________________________ Date: __________________

Return this completed application, with supporting materials, to the following school(s) you are applying to:


Attn: Regional Post-Baccalaureate Program
UCLA

School of Dentistry

Room 63-045

10833 Le Conte Avenue

Box 951668

Los Angeles, CA 90095-1668
(310) 794-2180

(310) 206-2688 (FAX)





For office use only:

DATE RECEIVED

INTERVIEW SCHEDULED

Application:

Date:

Statement of Intent:

Time:

DAT Scores:

Location:

Transcripts:

Interviewer:

Letters of Recommendation:







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