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    Intro to Dentistry Program Application 2024

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    patelmh6

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    © All Rights Reserved
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    Intro to Dentistry Program Application 2024

    Uploaded by

    patelmh6
    2 views2 pages

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    © © All Rights Reserved

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    Copyright:

    © All Rights Reserved
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    2 views2 pages

    Intro to Dentistry Program Application 2024

    Uploaded by

    patelmh6

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Introduction to Dentistry Summer Program

    Application for Visiting Undergraduate Students


    Fee: $300 (due upon acceptance into program)

    Date: _____________________

    Student’s Name: ______________________________________D.O. B _________Gender:___________

    City of Birth: _______________________________________________________________________

    Mailing Address: _______________________________________________________________________

    _______________________________________________________________________

    Email Address: _______________________________________ Telephone # _____________________

    Alternate Email Address: ________________________________________________________________

    Undergraduate School in which you are enrolled or attended:

    ____________________________________________________________________________________

    Address of School: _____________________________________________________________________

    _____________________________________________________________________

    Emergency Contact Name: _______________________________________________________________

    Emergency Contact #: ___________________________________________________________________

    Current Status of Student: Undergraduate Level: ____________________ Post Bac:_______________

    Ethnicity:*** ______________________

    1st Generation College Student ___ Yes ___ No

    Pell Grant Recipient ___ Yes ___ No

    Do you consider yourself disadvantaged and why? ___________________________________________

    _____________________________________________________________________________________

    Have you applied to any dental school ___Yes ___No


    When do you anticipate starting dental school: ____ Year

    Please attach a short essay separately (500-word limit) answering the following questions:

    1. Why are you interested in the dental profession?


    2. Tell us about any experience relevant to dentistry.
    3. What do you hope to gain from this program?

    Disclaimer:
    By submitting my application:
    1. I understand that my participation in this program in no way obligates Penn Dental Medicine to
    guarantee acceptance into the dental program

    Applicant signature: ______________________________________ Date: ________________________

    “The applicant has HEALTH INSURANCE COVERAGE (please provide proof), has received all
    APPROPRIATE IMMUNIZATIONS including the Covid-19 vaccine, and is in GOOD ACADEMIC
    STANDING” (Please provide an official copy of your transcript).

    Upon acceptance to the program, you will be sent a link to upload all relevant immunization records and
    permission forms.

    ***Colleges and universities are asked by many groups, including accrediting associations, to describe
    the ethnic/racial backgrounds of our students and employees. In order to fulfill these requests, we ask
    this question. This information is confidential and completely voluntary. The University of
    Pennsylvania does not discriminate with regard to race, color, sex, religion, national origin, sexual
    orientation or handicap.

    Please return your application by January 31st, by email to: Ms. Javita Lee
    [email protected]

    Transcripts can be mailed or sent electronically to the address or email address below:
    Dr. Beverley A. Crawford
    University of Pennsylvania School of Dental Medicine
    Evans 3rd Floor East
    Office of Diversity and Inclusion-Student Initiatives
    240 S 40th Street,
    Philadelphia, Pa 19104
    [email protected]
    Phone #: (215) 898-2840

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