Southern Utah University Utah Health Scholars Application

Name*

First NameLast Name
SUU T Number*
What semester do you plan on entering Utah Health Scholars*

Fall 2024Spring 2025Fall 2025Spring 2026
Have you previously been a member of Utah Health Scholars (known previously as Rural Health Scholars)?*

YesNo
Permanent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Hometown and State*
Permanent email (Not a school email)*
example@example.com
Cell Phone Number*
Cell Phone Provider*

VerizonAT&TT-MobileSprintCricketOther
Birthday*

MonthDayYear
Gender*

MaleFemalePrefer not to sayPrefer to self describe as: (non-binary, gender-fluid, agender, etc., please specify
Race/Ethnicity

African AmericanAsian/Pacific IslanderCaucasian/WhiteHispanicNative AmericanOther
High School Information
Did You Graduate from a Rural High School?*
ex. yes/no
Name of Your High School*
ex. Cedar High School, Canyon View High School, etc
ACT or SAT Score*
ex. 23
High School GPA*
ex. 3.51
Tell us of any classroom related honors (academic honors):
ex. Graduated with High Honors, Class President
Tell us about your out-of-classroom activities:
ex. Work, Leadership, Clubs, etc.
College or University Information
What do you plan to major in?*
ex: Biolology,Computel Science, Math, Engineering
What is your intended career?*

DentistDietitianHealthcare AdministrationNurseOccupational TherapistOptometristPharmacistPhysical TherapistPodiatristPsychiatristPhysicianPhysician AssistantVeterinarianUndecidedOther
Are you a transfer student?*

YesNo
University/College you transferred from:*
ex. University of Utah, Brigham Young University, Salt Lake Community College, etc.
Cumulative GPA
For all college work (ex. 3.55)
Total Credit Hours
ex 56 credit hours
Personal Statement
Include a one paragraph essay explaining why you want to go into medicine.*
Agreement and Signature
By completing this application, I agree to pay the $25.00 application fee and acknowledge that the UHS student fee of $187.50 will be added to my student account each semester. Your continuation in the program is automatic each semester until you notify us and complete an exit survey or graduate. Each student is required to register for UNIV 3000 each semester (or SCI 2120 the first semester) they are a member of UHS.
Signature*

Clear
Student Media Release Form
I, the student, consent to the release, exhibition, and distribution; without charge and without restriction or limitation; photographs of my likeness during my participation in the UHS program for any communications, educational, marketing, advertising, publicizing, promotional, and/or any other purpose which the releasees deem appropriate. I release the releasees from any and all types of claims and liability including without limitation for negligence or invasion of privacy of any and all types.

For purposes of this paragraph, “Photographs” include videotape, audio tape, film, photograph, electronic data or image, and/or any other recording medium. For purposes of this paragraph, “Likeness” includes my name, likeness, voice, biographical material, and/or other private and/or public facts and/or opinions. This authorization represents my written consent to disclose information from my experience to anyone the releasees see fit, including SUU Administrators, SUU and local media outlets, marketing materials, etc.

I understand that I may opt out of, or add limitations to, with no retroactive application, these provisions. To do so, I understand that I must fill out and sign the second page of this document and submit it to the Utah Health Scholars Office by email to uhs@suu.edu.

I understand that this form may be signed digitally. By signing digitally, I certify that I have read, understand, and agree to all of the above. If not signing digitally, I will sign the on the provided line below to certify that I have read, understand, and agree to all of the above.
Signature*

Clear
Media Release Form - Limitations
This authorization represents my written consent to disclose information to the specific organizations and individuals identified below.
I, print name*, hereby give my voluntary consent to the contract staff of the Utah Center for Rural Health to disclose the information indicated below:
To the following organization(s), individual(s), and/or publication(s):*

SUU Administrators (SUU President, Provost, Vice Presidents, Deans, Chairs, and Directors)SUU media outlets (University Journal, SUUTV, etc.)SUU Marketing CommunicationsSUU Alumni OfficeLocal media (The Spectrum, Iron County Today, and radio and TV stations)Office of Learning Abroad marketing materials (website, fliers, social media, etc.)Host institution abroad where I teach or conduct researchOther: Organization or Name
Type of information that can be disclosed:*

Name of the program I will participate in or have participated inPhotos taken by me and/or photos with me as a subjectEmails and other communications with the Office of Learning AbroadAchievements while teaching or researching abroadOther
Media Release Opt-Out: I do no permit any photos of my likeness or other information to be released by the Utah Center for Rural Health
By signing this release, I am giving the Utah Center for Rural Health my written consent to disclose the above-named information. I also understand that I may revoke this release at any time (via written request to the Utah Center for Rural Health) except to the extent that action has already been taken upon this release.
Signature*

Clear
Should be Empty: