University of Alabama at Birmingham (UAB) Academy for Addressing Health Disparities through Health Care Leadership

Application for Admission

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* 1. Name:

Last name:

First name:

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* 2. Address:

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* 3. Telephone Number:

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* 4. Email:

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* 5. Where did you attend high school? (city, state, zipcode)

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* 6. Are you currently enrolled at UAB?

Yes

Other (please specify)

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* 7. What year are you in college?

Freshman

Sophomore

Junior

Senior

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* 8. When do you expect to graduate?

Semester:

Year:

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* 9. What is your major?

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* 10. What is your most recent cumulative Grade Point Average (GPA)?

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* 11. Tell us your race or ethnicity (check all that apply):

American Indian or Alaskan Native

Black or African American

Native Hawaiian or Other Pacific Islander

Asian

Hispanic/Latina/Latino

White

Other (please specify)

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* 12. Are you the first person in your immediate family to attend college?

Yes

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* 13. Please provide names and contact information for two professors who know you. (name, phone number, email)

Professor 1

Professor 2

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* 14. Please discuss the factors that influenced your educational decisions to date. Also, describe your professional career goals for the future. (500-1000 words)