Southern Utah University Utah Health Scholars Application

Utah Health Scholars Application

SUU

Name *

First Name Last Name

SUU T Number *

What semester do you plan on entering Utah Health Scholars *

Fall 2022 Spring 2023 Fall 2023 Spring 2024 Fall 2024 Other

Have you previously been a member of Utah Health Scholars (known previously as Rural Health Scholars)? *

Yes No

Permanent Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Name of Hometown and State *

Permanent email (Not a school email) *

example@example.com

Cell Phone Number *

Cell Phone Provider *

Verizon AT&T T-Mobile Sprint Cricket Other

Birthday *

Gender *

Male Female Prefer not to say Prefer to self describe as: (non-binary, gender-fluid, agender, etc., please specify

Race/Ethnicity *

African American Asian/Pacific Islander Caucasian/White Hispanic Native American Other

High School Information

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? *

Are you a transfer student? *

Yes No

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 Communications SUU Alumni Office Local 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 research Other: Organization or Name

Type of information that can be disclosed: *

Name of the program I will participate in or have participated in Photos taken by me and/or photos with me as a subject Emails and other communications with the Office of Learning Abroad Achievements while teaching or researching abroad Other

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