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College of Health Sciences School of Community and Environmental Health

Supplemental Application for Admission – BSHS Program

I. Personal DataMale

Last Name (Family Name) First Name Middle Initial Female

Former Last Name (if any) Date of Birth (month/day/year) Age

Current Mailing Address (Street Address, P.O. Box) Mailing Address Line 2 (Apartment, Suite, Unit, Building, Floor etc.)

City or Town State/Province/County ZIP Code/Postal Code Country

Home Phone Number Cell Phone Number Email Address (Country/Area/City Code) (Country/Area/City Code)

Permanent address if different than mailing address:

Permanent Address (Street Address, P.O. Box) Permanent Address Line 2 (Apartment, Suite, Unit, Building, Floor etc.)

City or Town State/Province/County ZIP Code/Postal Code Country

Old Dominion University Details (Fill in all Details):

Advisor’s Name Advisor’s Site Number Advisor’s Phone #

ODU UIN# ODU Email

Entering Term: Fall Term 20___ Spring Term 20___

Bachelor of Science in Health Sciences Program:

Please print legibly and answer every question on this application. Acceptance into the BSHS program requires proof of eligibility (admission into ODU, current license/certificate to practice with at least 1-5 years of health-related work experience for those with a license and experience).

Date of Application _______________________

Summer Term 20___

Name:

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High School Name (if in US) High School City High School State

Are your parents/relatives graduates of Old Dominion University?

Yes No If yes, please list first name, last name, and relationship & UIN:

II. Old Dominion University programa. How did you learn about Old Dominion University BSHS program? (Please be specific)

School Advisor Name:

Advertisement: Newspaper/Magazine Internet Banner

Word of Mouth Name:

ODU Affiliate ODU Graduate ODU Student ODU Faculty Visiting Professor

Health Professional (MD, DVM, ETC.) Other

Email from ODU

Internet Search

Social Network: Facebook Twitter Other:

Campus poster College Fair/Professional Conference

Reference Book Other:

b. What factor(s) influenced your decision to apply to Old Dominion University BSHS program? (Please bespecific)

Placements upon graduation Clinical Sites network Online / Distance Learning Program

Large number of ODU grads in the workforce Student services Campus

Dual degree opportunities International experience

Other:

c. Were you contacted by phone or email after requesting information about Old Dominion Universityprogram?

Yes No If yes, please check one: Student Graduate Admission Counselor

Did this influence your decision to apply to Old Dominion University? Yes No

Name:

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III. Personal History1. Have you ever been convicted of a crime?

Yes No If yes, please explain:

2. Have you ever had privileges or a license (professional or otherwise) denied, suspended, and/or revoked?

Yes No If yes, please explain:

3. Have you ever been subject to a disciplinary inquiry by or before an oversight body or a licensing board?

Yes No If yes, please explain:

4. Have you ever been suspended or dismissed from an academic institution?

Yes No If yes, please explain and indicate which institution:

5. Have you ever applied to the BSHS program before?

Yes No If yes, when?

If you have previously applied, please explain how you have enhanced your application:

6. Was your schooling in English?

Yes No If yes, which years?

Name:

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IV. Employment, Volunteer Work, and Extracurricular Activities

You may submit a summary of work, research, and volunteer experience in a current CV or resume as an alternative to completing this section.

1. List EMPLOYMENT in the last four years, please provide hours worked per week:

Dates: Hours per week:

Description:

Dates: Hours per week:

Description:

Dates: Hours per week:

Description:

2. List VOLUNTEER WORK in the last four years, please provide hours worked per week:

Dates: Hours per week:

Description:

Dates: Hours per week:

Description:

Name:

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Dates: Hours per week:

Description:

3. List all EXTRACURRICULAR ACTIVITIES:

Dates: Hours per week:

Description:

Dates: Hours per week:

Description:

Dates: Hours per week:

Description:

V. Recommendation Letters:Provide names, email address and full contact information of your recommenders. Minimum of 3 letters are required. Recommendation Letters can be sent via email directly to the Program Director.

Name:

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VI. Academic Record1. Please indicate highest level of education:

If you are in the process of completing a degree, AS or AAS, please submit current transcript/academic record:List the institution and the degree program enrolled in:

2. Summary of Educational Experience: (Please list all institutions attended)

Grade/Mark Degree/Diploma/Exam Date Earned Institution Country Achieved

If you have an IB Diploma, please list subjects:

3. Standardized Examinations

A. Test of English as a Foreign Language (TOEFL) or English Language Testing System (IELTS): non-native speakers of English

Type of English Language Exam: IELTS, TOEFL-Paper, TOEFL-Computer, TOEFL-Internet Test Date Overall Score

If you are presently registered to take the any other standardized examination, please indicate:

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Name:

VII.EssayPersonal Statement: Please provide personal information that is otherwise not included in the application. Maximum 800 words. (Required of all candidates)

Name:

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Optional Essay: If you feel that your academic record and/or background is somewhat unusual, please state to the Committee on Admission a concise explanation of your path towards Health Services Administration.

Name:

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VIII. Checklist

1. Application filled in completely

2. Three (3) Letters of Recommendation

3. Academic Transcripts [Official/Unofficial]

4. Details of Professional Certifications (or)Licenses held:

5. Read, Understand and Accept all the following:

Note: YOUR APPLICATION WILL NOT BE REVIEWED UNLESS ALL APPLICABLE SECTIONS ARE COMPLETE.

I hereby certify that all of the information provided on this application is true. If it is subsequently discovered that false or inaccurate information was submitted, the University may nullify a candidate’s acceptance; if a student is registered, dismiss the student; or, if a degree has been conferred, rescind the degree.

Date:

I hereby apply for admission to the Bachelor of Science in Health Sciences Program at Old Dominion University. Proof of my eligibility for this program is attached (license, certification, or associate degree in a health related area, if applicable for the program that I am applying). I understand that three (3) letters of recommendation for admission into the program is required. The letters are from those persons who can attest your preparation for the rigor of the program. One (1) letter must be from your current faculty member /previous faculty member; [Two (2) letters from faculty are required if you are currently enrolled in any program of study]; One (1) from immediate job supervisor), and 1 (one) non-family person/person of repute. The application is incomplete if the three letters ofrecommendation on an official letterhead are not included and therefore, will not be reviewed. All pre-requisites must be completed priorto enrollment in the BSHS program. The Program Director must approve all admissions into the program and all internships.

Submission Deadlines for Application: February 15, May 15 and October 15

1. All the application materials should be sent,on or before the deadline via email to theProgram Director: bshshsa@odu.edu]

2. Your recommenders may choose to send theletters directly or as part of your applicationmaterials.3. If your application is incomplete after thedeadline, it will not be considered and will bediscarded.