<p> University of California, Berkeley National Institutes of Health (NIH) Bridges to the Baccalaureate Program Application Form – Community College Students</p><p>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. </p><p>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. </p><p>Name: Last First M.I. Address: Street City Zip Email address:______Female  Male  Cumulative G.P.A.: </p><p>Cell Phone: ______Alternate Phone: </p><p>Birth Date: ______Primary Language: </p><p>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 </p><p>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 </p><p>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? </p><p>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.</p><p> Please list the names of 4-year colleges/universities you were admitted to, if any: </p><p>Community College Students  Please submit unofficial transcripts from all colleges you have attended. Please include the classes you are taking currently.</p><p> Statement of Verification</p><p>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.</p><p>Signature: ______Date: </p><p></p><p>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:</p><p>University of California, Berkeley Community College Transfer Center, Attn: NIH Bridges to the Baccalaureate Hearst Field Annex-Building C Berkeley, CA 94720-1060</p><p>2(9/14)</p>