Public Health Summer Institute APPLICATION

Public Health Summer Institute and Pre-Medical Academy

Pre-College, High School Application Form
Applicant Information
Student Name*

First NameLast Name
Preferred Email for All Correspondences*
example@example.com
Birth Date*

MonthDayYear
Anticipated Grade in Fall 2023 (must be 9th, 10th, 11th, or 12th)*
Name of Current High School*
I pre-registered before March 15, 2023

YesNo
Official or Unofficial Transcript (most recent)*

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Letter of intent - please have a current teacher, career counselor, or other high school administrator write a brief note (3-4 sentences) specifying your intent to attend the Public Health Summer Institute and/or Pre-Medical Academy. Letters must be signed, dated, and have email and phone contact information for the writer. This does NOT have to be a letter of recommendation.*

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Anticipated college major*
If attending in person, which public health summer institute do you wish to attend?*

Season 1 near Harvard Campus in Cambridge/Boston, MASession 2 near Harvard Campus in Cambridge/Boston, MASession 3 near Yale Campus in New Haven, CTSession 4 near Gallaudet University in Washington, D.C.Session 5 near UCLA in Los Angeles, CA.Not attending one of the summer institutesNot attending in-person session
If attending in person, which pre-medical academy do you wish to attend?*

Season 1 near Harvard Campus in Cambridge/Boston, MASession 2 near Harvard Campus in Cambridge/Boston, MASession 3 near Yale Campus in New Haven, CTSession 4 near Gallaudet University in Washington, D.C.Session 5 near UCLA in Los Angeles, CA.Not attending one of the pre-medical academy sessionsNot attending in-person session
I am applying for one or more downloadable session(s)*

YesNo
REQUIRED ESSAY. Why do you want to participate in the Public Health Summer Institute? (In 250 to 500 words). *
OPTIONAL ESSAY. In 500 to 1000 words, describe one significant public health challenge and how you would solve it. Top essay(s) will be published in the HPHR Journal.
OPTIONAL ESSAY. In 500 to 1000 words, outline 2 critical issues facing the intersection of healthcare and social justice. Top essay(s) will be published in the HPHR Journal.
Ethnicity*

Black/African-American/African/Afro-CaribbeanAsian/Asian-AmericanLatinx/Latino/HispanicNative AmericanBiracial/MultiracialOtherPrefer not to discloseWhite American/Anglo-American/Caucasian
Gender*

MaleFemaleNon-BinaryTransgenderPrefer Not to Disclose
Primary Nationality*

North AmericanSouth AmericanEuropeanAfricanEast AsianSouth AsianAustrailianOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name*

First NameLast Name
Home Number
Cell Number*
E-mail*
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Email
On a scale of 1-5, how would you describe your understanding/knowledge of Public Health?*

1

2

3

4

5

1 is Worst, 5 is Best
On a scale of 1-5, how would you describe your understanding/knowledge of Social Justice?*

1

2

3

4

5

1 is Worst, 5 is Best
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

ALL INFORMATION SUBMITTED HEREIN IS TRUTHFUL AND ALL ESSAYS COMPLETED WERE CONCEIVED AND WRITTEN BY THE REGISTRANT/APPLICANT.

I ACKNOWLEDGE THAT I HAVE READ THE PRIVACY, REGISTRATION, AND CANCELLATION DOCUMENTATION (https://bcph.org/institute/) AND AGREE TO LAWFULLY ABIDE BY THESE TERMS GIVEN ANY FUTURE ISSUE.
Signature*

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Date*

MonthDayYear
Date
View https://bcph.org/institute/ for additional information. Please email communications@bcph.org with extra questions with "Public Health Summer Institute or Pre-Medical Academy" in the subject line.
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Early Application/Registration Fee (non-refundable)For registration occurring from March 15 to April 15, 2023, MIDNIGHT EST
$25.00

Total

$0.00
Please enter your cell phone information for application receipt.*
Please verify that you are human*

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Public Health Summer Institute and Pre-Medical Academy

Applicant Information