The

UNIVERSITY
of
CHICAGO

Chicago Careers
in
Health Professions

CCIHP FELLOWS
APPLICATION
2011-2012

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 THE UNIVERSITY OF CHICAGO
CHICAGO CAREERS IN HEALTH PROFESSIONS
1116 E. 59th St., Harper Memorial, West Tower, #406
Chicago, IL 60637
(773) 702-8611

CONTACT INFORMATION

First Name ________________________________________ UCID ____________

Middle Name ________________________________________ Sex M F
Last Name ________________________________________
Email ________________________________________
Cell Phone ________________________________________
Emergency ________________________________________
Contact
EDUCATIONAL BACKGROUND
PHOTOGRAPH

GPA Overall ___________ Please attach a recent photo of yourself.

GPA Science ___________ The image should be a passport-style
photo (i.e., a head shot, with your face
GPA Non-Science ___________ clearly visible).

Major(s) _________________________________
Graduation Year ___________

TIME COMMITMENT
Can you dedicate 6-7 hours a week to your work as a Fellow? Y N
Can you attend 2-3 CCIHP events per quarter? Y N
Can you collaborate with the other Fellows to deliver three events during the year? Y N
Will you be available to assist with events during Orientation Week? Y N
What other commitments will you have during the academic year? Please be specific.

REFERENCES
Please provide contact information for two individuals (faculty members, former CCIHP Fellows, College students,
advisers, supervisors from work or co-curricular experiences, etc.) who can speak on your behalf. Indicate the
capacity in which you know them.

1 _______________________________________________________________________
2 _______________________________________________________________________

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 PERSONAL CHRONOLOGY
Tell us briefly about your background. See the instructions for examples.

YOU AS A FELLOW
Knowing what you know now, what would you do differently during your first year
if you could do it over? Or, what advice might you give a first-year student?
Or, describe a program or event you might be interested in developing next year.

HEALTH PROFESSIONS INTEREST

What does a career in health and medicine mean to you? How would being a CCIHP Fellow support your efforts?

SOCIAL ENGAGEMENT AND SKILLS

How have you engaged communities through service, leadership, or volunteering? What personal and
interpersonal skills have enabled you to succeed as a leader and collaborator in these pursuits?

PLAY
Tell us about what you like to do for fun.

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 RESUME
Please insert a one-page resume.

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 INSTRUCTIONS

Personal Chronology: Tell us briefly about your background, including (but not limited to)
your life up to your matriculation into the College. Examples:

Max Jones
Although born in Oakland, California, I was raised in Chicago with my significantly younger
twin sisters—I’m 12 years older. My father lost his job when I was seven and we moved to
Chicago to be closer to his family. My mother, an elementary school teacher for the San
Francisco Unified School District, changed careers and now works at DeVry University in
administration. While a student at Whitney Young High School, I played on the basketball team
for two years. I was also active in my local community, founding a youth brass band with the
support of my church and volunteering at Pets Are Worth Saving (PAWS), an animal shelter. It
was there my interest in veterinary medicine began.

Maura Foley
I lived in Ireland until age two, where my mother (an American) worked at the US Embassy in
Dublin. My father stayed at home for these two years, but he returned to work at a garment
import and export company when we moved to Washington, D.C. Because of my mother’s job,
we moved around a lot. I went to elementary school in Egypt and Venezuela and I completed
high school in Hawaii, where my family ultimately settled. While in Hawaii, I became fascinated
with biology and participated in a summer research program on coral reef preservation
associated with Hawaii Pacific University. I was also involved with my high school’s
cheerleading team and played intramural volleyball for a year.

Complete this application in Adobe Reader or Adobe Acrobat. The software must be Version
9 or later. You can download Adobe reader at http://get.adobe.com/reader/.

Note for Mac users: When you open .pdf files on a Mac, the operating system will, by default,
view the file in an application called Preview. Preview will not allow you to save information
that you input into the form. Instead, download Adobe Acrobat Reader, which will allow you to
use the form correctly.

When saving this file, use the following format for the file name: “CCIHP Fellows Application
Your last name”

Submit your completed application by email to Cindy Domecki (cdomecki@uchicago.edu) by

9:00 a.m., Friday, April 29.