Camp Counselor Application - Office for Diversity & Health Equity

HEALTH CARE SUMMER INSTITUTECAMP COUNSELOR APPLICATION(Please type or print clearly)Name__________________________________________ Email__________________________________(You will be contacted by email)SS#_______ _____ ________ Gender F___ M___ Date of Birth: _______/_________/__________Address: ________________________________________________Local Telephone (_____)_____________City: _____________________________________ State: _______Zip: ____________Permanent Address: ___________________________________________Telephone (_____)____________City: ____________________________________ State: _______ Zip: ____________Where/How did you hear about the HCSI? ___________________________________________________________________________________________________________________________________________Date of Admission to UF__________________________________ Cumulative UF G.P.A.___________Classification ____________________________________________Major Field of Study______________________________________ Expected Graduation Date________OTHER COLLEGES AND UNIVERSITIES YOU HAVE ATTENDED:UNIVERSITY DEGREE YEAR________________________________________________________________________________________________________________________________________________________________________HAVE YOU LIVED IN A RESIDENCE HALL OR GROUP LIVING EXPERIENCE?(i.e., military, fraternity/sorority, etc.) Yes ____ No____HALL/GROUP LIVING DESCRIPTION__________________________________________________________________________________________________________________________________________________________________________________4