To which participating organization are you a part?
* must provide value
Department for the Blind and Vision Impaired (DBVI)
Capital Area Health Education Center (CapAHEC)
First Name:
* must provide value
Last Name:
* must provide value
Preferred Name (nickname):
Current Mailing Address:
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Building number, street name
City:
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State:
* must provide value
Country:
* must provide value
Is your current mailing address also your permanent address?
Yes
No
Permanent Address (if different from above):
Full permanent address if different from current mailing address previously listed above
Date of Birth:
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Today M-D-Y
Email Address:
* must provide value
All application communication will be sent to this email address
If none, type N/A and move to the next question
Primary Phone:
* must provide value
If none, type N/A and move to the next question
How did you hear about our program?
Dept. for the Blind and Vision Impaired
Capital Area Health Education Center
VCU Pipeline Website (www.dhsd.vcu.edu)
Internet search
Social media (Facebook, Twitter, Instagram, etc.)
VCU event (Open House, Preview Day, etc.)
High school event (College Fair, field-trip, etc.)
Program flyer/brochure by mail/email
Former participant
Pre-health advisor/School counselor
VCU Pipeline Ambassador
Other
Please give details about the "other" method that you heard about our program from:
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How would you describe your current neighborhood?
Urban
Suburban
Rural
Reservation
Islanders
Other
Please describe your "other" location:
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The following is about your:
* must provide value
Mother
Father
Legal Guardian
Name:
* must provide value
Full guardian name
Is their address also the applicant's permanent address?
Yes
No
Street Address:
* must provide value
If the same as applicant permanent mailing address, redo previous question to indicate "yes." If different than applicant permanent mailing address, indicate building number, street name and complete remaining questions
City:
* must provide value
State:
* must provide value
Email Address:
* must provide value
Primary Phone:
* must provide value
Highest level of education completed:
* must provide value
No High School diploma High School diploma, or equivalent College or university undergraduate degree College or university graduate degree
The following is about your:
* must provide value
Mother
Father
Legal Guardian
Not applicable (single parent)
Name:
* must provide value
Full guardian name
Is their address also the applicant's permanent address?
Yes
No
Street Address:
* must provide value
If the same as applicant permanent mailing address, type "Same" for all address fields and move on to the next question. If different than applicant permanent mailing address, indicate building number, street name and complete remaining questions
City:
* must provide value
State:
* must provide value
Email Address:
* must provide value
Primary Phone:
* must provide value
Highest level of education completed:
* must provide value
No High School diploma High School diploma, or equivalent College or university undergraduate degree College or university graduate degree
Citizenship:
* must provide value
Citizen
Permanent Resident
Neither
If not US, Visa Type & Expiration Date:
Please indicate your Hispanic or Latino ethnicity:
Please describe "other" race selection:
Less than $10,000 Between $10,000 and $20,000 Between $20,000 and $30,000 Between $30,000 and $40,000 Between $40,000 and $50,000 Between $50,000 and $60,000 Between $60,000 and $70,000 More than $70,000
Disadvantaged status: Do you consider yourself to be economically, educationally, or socially disadvantaged?
Yes
No
If yes, please explain in 250 words or less:
* must provide value
Note: Applications received that are missing a personal statement will not be reviewed
* must provide value
How interested are you in attending a Professional Health Science School at VCU?
Very
Somewhat
Not Sure
Very Little
Not at all
Health Career interest (check all that apply):
Education level/grade as of April 1,2019
9th grade 10th grade 11th grade 12th grade College freshman
Current/most recent School
* must provide value
Name of current/most recent school
Dates Attended:
* must provide value
MM/YYYY format
Graduation Date:
* must provide value
MM/YYYY format
GPA & Scale (ie. 4.0)
* must provide value
Do you have a second institution that you have attended to list?
Yes
No
Second Institution:
* must provide value
Dates Attended:
* must provide value
Graduation Date:
* must provide value
GPA & Scale (ie. 4.0)
* must provide value
Do you have a third institution that you have previously attended to list?
Yes
No
Third Institution:
* must provide value
Dates Attended:
* must provide value
Graduation Date:
* must provide value
GPA & Scale (ie. 4.0)
* must provide value
Do you have any academic honors or awards?
* must provide value
Yes
No
Academic Honors and Awards Received:
* must provide value
Please list any academic honors and awards, along with dates received. If none, type N/A and move to the next question
How many organizations or activities would you like to list?
One
Two
Three
Four
Five
Current/Most Recent Organization:
* must provide value
If none, type N/A and move on to next section
Dates Attended:
* must provide value
MM/YYYY format
Responsibilities:
* must provide value
Supervisor/leader contact information:
* must provide value
Contact name, phone or email
Second Organization:
* must provide value
If none, type N/A and move on to next section
Dates Attended:
* must provide value
MM/YYYY format
Responsibilities:
* must provide value
Supervisor/leader contact information:
* must provide value
Contact name, phone or email
Third Organization:
* must provide value
If none, type N/A and move on to next section
Dates Attended:
* must provide value
MM/YYYY format
Responsibilities:
* must provide value
Supervisor/leader contact information:
* must provide value
Contact name, phone or email
Fourth Organization:
* must provide value
If none, type N/A and move on to next section
Dates Attended:
* must provide value
MM/YYYY format
Responsibilities:
* must provide value
Supervisor/leader contact information:
* must provide value
Contact name, phone or email
Fifth Organization:
* must provide value
If none, type N/A and move on to next section
Dates Attended:
* must provide value
MM/YYYY format
Responsibilities:
* must provide value
Supervisor/leader contact information:
* must provide value
Contact name, phone or email
Have you taken the SAT?
* must provide value
Yes
No
If not taken, please skip to the next question
If not taken, please skip to the next question
If not taken, please skip to the next question
If not taken, please skip to the next question
Have you taken the ACT?
* must provide value
Yes
No
If not taken, please skip to the next question
If not taken, please skip to the next question
If not taken, please skip to the next question
If not taken, please skip to the next question
If not taken, please skip to the next question
If not taken, please skip to the next question
Have you taken Graduate/Professional School Entrance Exams (DAT, GRE, MCAT, PCAT)?
* must provide value
Yes
No
If not taken, please skip to the next section
If not taken, please skip to the next section
Anticipated/Planned exam date:
If not taken, please skip to the next section
Recommendation Form
Please download the following recommendation form and complete the first page. After completing the first page, please either print and send or email the form to your references.
Applications require 1 to 2 references based on requirements. Please see program page for details www.dhsd.vcu.edu
Relationship to yourself:
Acceptable references are academic, work or organization related. No family relations please.
Applications require 1 to 2 references based on requirements. Please see program page for details www.dhsd.vcu.edu
Relationship to yourself:
Acceptable references are academic, work or organization related. No family relations please.
By checking you are certifying the information filled out on this application is accurate.
* must provide value
Do you wish to be contacted in the future, regarding other VCU Health Career Pipeline opportunities?
* must provide value
Yes
No
Submit
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