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The name of the program.
Primary host or implementing organization for the program
Such as year established, years in operation, any prior program this program may have grown out of, etc.
Select all that apply.
Is there a limit on the number of program participants (e.g., in a given year or offering)?
Please briefly describe limit(s) on the number of participants.
What is the duration of each participant’s involvement in the program? (e.g., 10 weeks, 1 semester, 2 years)
Select all that apply.
Please briefly describe any programs that this program articulates with (i.e., participants are able to flow into the program from another program and/or enter another program after completing this one).
Please briefly describe umbrella organization(s) and/or program network(s) with which this program is affliated at the regional, state, or national level (e.g. AHEC, HRSA HCOP programs, etc.).
Does this program include in-person and/or remote (virtual) components?
Please briefly describe the location(s) for the in-person component of the program.
The county where this program is primarily located.
Please briefly describe the virtual (remote) component of the program (technology requirements, synchronous or asynchronous, etc.)
When do program activities take place (e.g., summer, throughout a semester or academic year, afterschool hours, weekends)?
What are the primary desired outcomes of this program and indicators of success? This can include things like: A and B grades in science courses, improved performance on practice MCAT exam, acceptance to health professions graduate program, etc.
What are the main area(s) of focus for the program?
Please briefly describe the program’s academic instruction component.
Please briefly describe the program’s academic skills component.
Please briefly describe the program’s academic support component.
Please briefly describe the program’s application guidance/support component.
Please briefly describe the program’s conditional admission component.
Please briefly describe the program’s career exploration component.
Please briefly describe the program’s mentoring component.
Please briefly describe the program’s networking component.
Please briefly describe the program’s skills development component.
Please briefly describe the program’s research component.
Please briefly describe the program’s other components.
Please briefly describe the findings of any evaluations that have been performed of this program, or link to any reports available for sharing.
What types of eligibility criteria or priorities does the program have for participants?
Brief description of eligibility criteria and/or priorities relating to academics (e.g. required prior coursework or major, minimum GPA).
Brief description of eligibility criteria and/or priorities relating to racial or ethnic group membership.
Brief description of eligibility criteria and/or priorities relating to socio-economic background.
Brief description of other eligibility criteria and/or priorities.
What are the required components for applications to the program (e.g., statement of purpose, transcript, letters of recommendation/references)?
Are there any participant costs, like tuition or other fees?
Brief description of participant costs.
Do participants receive financial assistance (e.g. stipend) or other support (e.g. housing, scholarship)?
Brief description of financial or other support for participants.
Number of full-time-equivalent paid program staff
Approximate annual program budget (excluding in-kind donations).
Please list any recent sources of funding for this program.
Please list name(s) of funding organizations
Please describe program revenue
Does this program receive any in-kind resources that support its operation (e.g., donated office space, volunteers, tuition waivers for participants)?
Please briefly describe in-kind support received by the program.
Name and title of program contact person
Phone number of program contact
Please provide the name of the person submitting this form in case we have any questions. (Will not be shared publicly)
Please provide your email address in case we have any questions. (Will not be shared publicly)
Please share any additional information about the program or other comments.
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