Public Health Early Admissions Student Track

A COLLABORATIVE INITIATIVE BETWEEN - - - of Kearney - University of Nebraska Medical Center Application Form Instructions: Please complete all sections, print, sign, and submit along with all supporting documentation (see page 2) to the PHEAST Campus Representative at your school. Application Deadline is March 15th.

Please indicate your primary public health concentration area of interest at this time. Click here for a current listing of concentration areas offered through the UNMC College of Public Health, MPH Program. Concentration Area:

Name Last: First: Middle Int.

Address: Street City State Zip:

Phone Number: Preferred E-mail:

Date of Birth Are you a Nebraska resident? Yes No (mm/dd/yy):

Race/Ethnicity: Supplying this information is optional and is not required for admission. This data is for reporting purposes. Please indicate your ethnicity: Please indicate one or more races:

American Black/ Native Hispanic or Not Hispanic or Indian/Alaska Asian African Hawaiian/ White Latino Latino Native American Pacific Islander

Are you the first in your immediate family to go to college? (Choose "yes" if neither of your parents/primary care giver Yes No obtained a Bachelor's degree or higher.)

High School Attended:

Name: City: State: Year of Graduation:

Please indicate the undergraduate instituion you currently attend:

Chadron State College Peru State College Wayne State College University of Nebraska at Kearney

Colle ge G PA : Please indicate your college GPA and submit your official college transcript along with this application.

Please include your college major(s):

Please include your college minor(s):

Planned/Intended Graduation Date from Undergraduate Institution (Month/Year):

How many credit hours have you completed towards your undergraduate program of study?

1 of 2 References: Please provide three letters of recommendation (two of which must come from the college you are attending). Please list below the persons that you have asked to write letters of recommendation for you.

Name: Title:

E-mail: Telephone:

Name: Title:

E-mail: Telephone:

Name: Title:

E-mail: Telephone:

The above information, along with all supporting documentation, are submitted as an application for the Public Health Early Admission Student Track (PHEAST); a collaborative health professions pipeline program between Chadron State College, Peru State College, Wayne State College, University of Nebraska-Kearney, and the University of Nebraska Medical Center. By signing this application, you attest that the information you provided is correct to the best of your knowledge, and that you have reviewed the PHEAST Standards document which outlines program philosophy, student requirements and expectations.

Signature: Date:

Supporting Documentation ***In order for applications to be considered for review, all supporting documentation must be received by March 15th***

• Personal Statement o Please type a 500 word essay (double spaced, Calibi font, size 11) that describes why you want to become a public health professional, and what academic and personal characteristics would make you a successful candidate who pursues a graduate education in public health. • Plan of Study /Matriculation Timeline • Resume o Please submit your professional resume. Your resume should state your: o Career Objectives/Goals o Education History o Employment History o Special Accomplishments (honors/awards/offices held) o Community Service/Civic Engagement

• Official Transcript(s)

• 3 Letters of Recommendation

o Please request for your official transcripts and letters of recommendation to be submitted electronically in pdf format to [email protected].

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