Request for a Pre-Health Committee Interview/Evaluation

Request for a Pre-Health Committee Interview/Evaluation
Name*

First NameLast Name
Student ID*
e.g., 001234567
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Email*
example@albany.edu
Phone Number*

Area CodePhone Number
Graduation Date*
Year of entry into a health profession school*
Health Profession Area(s) of application*
Choose one of the following:*

I am currently an undergraduate student at the University at Albany in a degree program and have completed at least 30 credit hours at AlbanyI am enrolled through general studies at the University at Albany and have taken all of the prerequisite science courses for my chosen health profession area of application as a post-baccalaureate student at Albany(must have completed at least 30 credit hours here)I am applying to an Early Assurance program/(soph) or joint degree SUNY/Opt. (soph)I am a graduate of the University at Albany
Year/degree:*
Please check each statement below indicating that you have read and acknowledged each statement.*

I acknowledge that I am aware that students receive only one opportunity to interview with the Pre-Health Advisory Committee. I request my single opportunity to interview with the Pre-Health Committee during the SPRING semester. I understand that interviews are conducted FEBRUARY to APRIL in person on campus and my request may be accommodated only if I submit all required documents including all required letters of recommendation by the stated deadline.I am informed that it is required that I have completed the prerequisite pre-health coursework courses prior to the Spring semester.I am aware that the committee expects me to have gained at least 50 hours of volunteer or employment experience in the health field working directly with patients and to provide a letter of recommendation about this experience. Shadowing cannot be used for this requirement.I understand that if the information in my pre-health file reveals that I am not currently a competitive applicant that the Pre-Health Committee may not be able to offer a strong recommendation on my behalf and it is also unlikely that I will receive an acceptance to a health profession school.I understand that the Pre-Health Committee strongly encourages students to improve their weak areas (academic or non-academic) and is willing to interview students in the following SPRING semester (provided all aforementioned conditions are met) for the NEXT application year.I accept my responsibility to ensure that all required materials are received into my pre-health file by the stated deadline. Those with incomplete files do not receive interviews. If I do not arrive on time at the proper location for my interview, I may forfeit my chance to be interviewed. I honestly believe that I am currently a competitive applicant for a professional school and I am prepared to meet with Pre-Health Committee members.I understand that my pre-health committee evaluation and letters of recommendation in my pre-health file are intended for a health professions school application only and the pre-health office will retain my committee letter and letters of recommendation for 5 years.
Click the "next" button below to continue to the Release of Pre-health Committee Packet and Waiver or Retention of Rights.

Release of Pre-health Committee Packet and Waiver or Retention of Rights
In accordance with the Family Educational Rights and Privacy Act of 1974, P.L. 93-380 (amended), reference to Section 438(a)(1)(B).
Authorization and Waiver for Committee Evaluation
If you wish to obtain a Committee Evaluation to support your application to professional school, you must complete and sign the sections below.
Authorization
Check below to indicate that you have read and acknowledged the following statement.*

I hereby authorize the Pre-Health Committee or their representatives to (1) obtain my transcript(s) from the Registrar’s Office and (2) evaluate my scholastic and personal qualifications and share their assessment with graduate and professional schools in connection with my endeavor to obtain a position for further study in a health-related program.
Waiver
The function of the Pre-Health Committee is to provide advice and guidance to students seeking admission to health profession schools. Our policy of discussing fully and completely with a student the information and records available to us pertaining to him/her will remain unchanged regardless of whether or not a waiver, as specified under the Privacy Rights Act, is signed. A number of faculty members feel that to be fully effective, evaluations should be confidential – in other words, that confidentiality is what makes an evaluation most worthwhile. We, therefore, urge that you carefully consider whether or not to sign the waiver of your right of direct access. Remember: whether you sign the waiver or not, nothing is transmitted unless you tell us to do so in writing, and it is your right to know whose statements are being forwarded.
Choose ONE of the following:*

I hereby voluntarily waive my right under the Family Educational Rights and Privacy Act of 1974 to review letters of recommendation that I wished forwarded to professional schools.I wish to exercise my right under the Family Educational Rights and Privacy Act of 1974 to review my letters of recommendation that I wished forwarded to professional schools.
By signing (typing your legal name) in the space below, you are certifying that all information on this form is correct and that you are the person completing this application.

When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Request for a Pre-Health Committee Interview/Evaluation

Release of Pre-health Committee Packet and Waiver or Retention of Rights

Authorization and Waiver for Committee Evaluation

Authorization

Waiver