* Last Name:

* First Name:

Middle Initial:

* Gender:
Male Female

* Birth Date mm-dd-yyyy:

* Place of Birth:

* Street Address:

* Borough:

* ZIP Code:

* Home Phone Number xxx-xxx-xxxx:

* Cell Phone Number xxx-xxx-xxxx:

* Email Address:

* How did you find out about the Health Literacy Fellowship?:

PART 2: Academic Record

* Name of Medical School:

* Expected Year of Graduation:

Cumulative GPA (if you are a pass/fail institution, please write in "pass/fail"):

* Intended Area of Specialization :

* Name of Faculty Advisor:

* Address of Faculty Advisor:

* Undergraduate Institution:

* Degree:
BA BS

* Date Conferred:

* Cumulative Undergraduate GPA:

* Major:

* Minor:

* Other Academic Degrees:

PART 3: Awards & Activities

List any awards and honors you have achieved in the last three years.

Year:

Award Description:

Year:

Award Description:

Year:

Award Description:

Please choose three extracurricular activities that you have participated in that were/are the most important to you.

Activity 1
Please describe the activity and your role in it:

One sentence, why you chose to be a part of it:

One sentence, what you learned from it:

Activity 2
Please describe the activity and your role in it:

One sentence, why you chose to be a part of it:

One sentence, what you learned from it:

Activity 3
Please describe the activity and your role in it:

One sentence, why you chose to be a part of it:

One sentence, what you learned from it:

Please choose the two employment experiences that you learned the most from.

Employer 1:

Address:

Dates of Employment:

Job Title:

Key Responsibilities:

What you learned from the experience:

Employer 2:

Address:

Dates of Employment:

Job Title:

Key Responsibilities:

What you learned from the experience:

PART 4: Essays

The purpose of these essays is to learn more about you, your interests, and your thoughts on health, medicine, and health literacy.

Please answer the following short-answer essays in 500 characters (approximately 100 words) or less:

* Name an individual (thinker, scholar, writer, artist, politician, etc.) who has influenced your thinking about health and medicine in America. How?

* What is one ‘cause’ you are passionate about and why?

Please answer the following essay in 1000 characters (approximately 200 words) or less:

* Your patient barely speaks English. You think that she is complaining of fever, nausea, and headaches for two weeks. You are fairly certain she cannot understand you. What do you do?

Please answer the following essay in 2500 characters (approximately 500 words) or less:

* The Health Literacy Fellowship strives to cultivate the development of future physicians equipped to communicate clearly and effectively with people of varying literacy levels and from diverse backgrounds in a multicultural society. What about your background and experiences will you bring to this program that will enable you to be a successful health literacy fellow and will enrich the experience for the other fellows in your cohort?

* Is there any additional information about yourself that you would like us to know?
1000 characters (approximately 200 words)

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