School of Pharmacy UNIVERSITY OF WISCONSIN - MADISON Apply 2019 Pharmacy Summer Program application deadline – March 31, 2019 Thank you for your interest in applying to the 2019 Pharmacy Summer Program! To have a completed application you must submit the online application AND upload the following required materials: Completed online application form (below) Completed supplemental application and essay form (please download form and we will send you a link to upload your completed form) Official high school transcript (a link and password will be emailed to you for file upload) One letter of recommendation from a science teacher (an email will be sent to your teacher with a link to upload the letter) Students who identify as African-American/Black, Native American/American Indian, Latino/a, Laotian, Vietnamese, Hmong, Cambodian are especially encouraged to apply. Students whose parents didn’t graduate from a 4-year degree granting institution, or who quality for free and reduced lunch are also encouraged to apply. We look forward to reading your applications. Lindsey DeCarlo, Outreach & Recruitment Coordinator Pharmacy Summer Program Director UW-Madison School of Pharmacy 777 Highland Avenue, 2220 Rennebohm Hall Madison, WI 53705 email@example.com Applicants will be notified by email of their acceptance into the Pharmacy Summer Program in May. Summer Program Application Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone Number (no dashes)Email* Date of Birth (xx/xx/xxxx)* Name of High School*High School - City & State*Please enter your high school's location - city & statePreferred Gender PronounsHe/HimShe/HerThey/ThemZe/HirPrefer not to respondBackground InformationCheck if any of the following apply to you: I am the first generation in my family to attend college (neither my mother nor my father attended college). I am from a family that receives public assistance (e.g., Aid to Families with Dependent Children, food stamps, Medicaid, public housing) or I receive public assistance. I am from a family that lives in an area that is designated as a Health Professional Shortage Area or a Medically Underserved Area. English is not my primary language. I am from a school district where 50% or less of graduates go to college or where college education is not encouraged. I attend a high school at which a low percentage of seniors receive a high school diploma. I attend a high school at which many of the enrolled students are eligible for free or reduced price lunches. Wisconsin Resident*YesNoIf no, State of residency:U.S. Resident*Are you a U.S. resident?YesNoIf no, Country of residency:Racial Background(please check all that apply):African American or BlackCambodianCaucasian or WhiteHmongNative Hawaiian or Pacific IslanderLaotianLatino/aVietnameseAmerican Indian/Alaska NativeIf you identify as American Indian/Alaska Native, then tell us your tribal affiliation.:Cumulative Weighted High School GPA:Unweighted GPA:Name of science teacher writing letter of recommendation.*One letter of recommendation from a science teacher. First Last Email of science teacher writing recommendation*We will send an email to your teacher with instructions on how they can submit.