University of California, Berkeley National Institutes of Health (NIH) Bridges to the Baccalaureate Program Application Form – Community College Students

Thank you for your application to the UCB Bridges to Baccalaureate Program. The goal of the UCB B2B Program is to increase the number of African Americans, Hispanic Americans/Latinos, Native Americans and Pacific Islander community college students who transfer to 4-year colleges/universities in biomedical sciences (not nursing or allied health) and graduate in these majors. Per the requirements of the funder, eligible students must be a member of one or more of the target ethnicities/races, U.S. Citizens or Permanent Residents and have not already received a B.A./B.S. Academic performance & potential are considered.

Students accepted into the program receive tutoring/academic coaching, one-to-one transfer preparation/assistance, exposure to top level research labs and, depending upon academic and program performance, the opportunity to conduct full-time paid summer research in the lab of a Berkeley professor.

Name: Last First M.I. Address: Street City Zip Email address:______Female  Male  Cumulative G.P.A.:

Cell Phone: ______Alternate Phone:

Birth Date: ______Primary Language:

Highest Degree planned: Certificate AA/AS BA/BS Master’s PhD Medical Degree Law Do you plan to transfer to a 4 year college? Yes No Don’t Know Intended major after transfer (if known) ______Intended transfer date (if known) 4-year colleges/universities you are interested in applying to (if known) Current Career Goals(state all applicable): Do you have a BS/BA or higher degree? Yes No Race/ethnicity (required) (Check all that apply): African-American Hispanic/Latino/Chicano Pacific Islander/Hawaiian Native Native-American/Alaskan Native Asian-American Caucasian Other Citizenship Status: U.S. Citizen U.S. Permanent Resident U.S. Veteran?: Yes No Highest Education Completed by your Parents/Guardians:  Mother/Parent-Guardian 1: Less than HS High School Some College AA/AS BA/BS Graduate Degree  Father/Parent-Guardian 2: Less than HS High School Some College AA/AS BA/BS Graduate Degree  Community College Enrollment Status:  I will not be enrolling at any four year institution during the 2017-2018 academic year (except through concurrent enrollment): Yes No  For the academic year 2017-2018, I will enroll in community college: Part-time Full-time

Community College(s) you plan to attend in this semester: Chabot College Merritt College Laney College Berkeley City College College of Alameda Current/Past Participation in Academic Preparation/Outreach Programs, if applicable (check all that apply) EAOP EGC Upward Bound Upward Bound Math & Science Destination College Y-Scholars AVID Puente Black Student Union UCB Transfer Alliance Project (TAP) East Bay Consortium (EBC) Boys & Girls Club Other

How many hours per week do you plan to work this semester? Have you ever participated in a non-class lab research program? (e.g. iCLEM, Biotech Partners?) Yes No If yes, please list program name(s) and lab(s) where you conducted research?

Academic Information:  Please list below any Advanced Placement (AP) or International Baccalaureate (IB) courses you have taken and/or are currently taking, and include available exam scores.

 Please list the names of 4-year colleges/universities you were admitted to, if any:

Community College Students  Please submit unofficial transcripts from all colleges you have attended. Please include the classes you are taking currently.

 Statement of Verification

I hereby certify to the best of my knowledge that all information submitted on this application and in my attached transcripts is accurate. I authorize the NIH Bridges to Baccalaureate Program to access my college transcripts and to share this data with my community college for advising purposes.

Signature: ______Date:

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Completed application, with transcripts, should be either scanned (via PDF) and emailed to [email protected] (Chabot students) or [email protected] (Peralta students), or mailed to the address below:

University of California, Berkeley Community College Transfer Center, Attn: NIH Bridges to the Baccalaureate Hearst Field Annex-Building C Berkeley, CA 94720-1060

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