2013

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Name _____________________________________________________________________________________________ (Last,

First,

Middle / Maiden)

Primary Phone (_________)__________-______________ Secondary Phone (_________)__________-______________ Home Address ______________________________________________________________________________________ Street Number Street Name

Apt

City

State

Zip

E-Mail Address_____________________________________________@___________________________.____________ Birth Date __________/__________/__________ Month

STAR Class (circle one)

Day

2007

Year

2008

2009

2010

2011

2012

Last/current high school attended(ing): __________________________________________________________________________________________________ What year did you graduate from high school? (circle one)

2007

2008

2009

2010

2011

2012

2013

At which college or university are you currently enrolled? ___________________________________________________ What is your major/field of study? ______________________________________________________________________ If you are a high school graduate and not enrolled in a college/university, describe your current occupation, plans, etc. __________________________________________________________________________________________________ __________________________________________________________________________________________________ Have you attended any other colleges or universities? If yes, please explain. ____________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Were you offered any scholarships or grants to attend college? If so, please list them.____ ________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Please list some of your most important collegiate accomplishments. With which clubs/organizations are you currently involved? __________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

What are your future education plans? (degrees you plan to receive, universities you plan to attend, etc.) __________________________________________________________________________________________________ __________________________________________________________________________________________________ What are your future career plans? _____________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Do you plan to stay in Louisiana for your education?

YES

NO

Do you plan to stay in Louisiana for your career?

YES

NO

If you answered NO to either of the above two questions, please explain why. __________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ What is your most memorable experience, class, or rotation from the STAR (SSYA) Program? __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Have you participated in any other programs that are offered through Academic Outreach (job shadows, site visits, Medical Explorers, etc.)? If so, please list them below. __________________________________________________________________________________________________ _________________________________________________________________________________________________ Have you participated in any other opportunities or programs through Ochsner Health System or have you been/are you currently employed by Ochsner? (volunteering, research assistant, personal job shadow, etc)? If so, please list below. __________________________________________________________________________________________________ __________________________________________________________________________________________________

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