The Elma Vines Summer Health Academy 2022
Contact Program Coordinator, contact@vinesmedical.org with any questions or concerns.
*Please send your (1) letter of recommendation via email to: contact@vinesmedical.org 
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Email *
Name: *
first. middle initial. last
Local Mailing Address: *
number & street. city. zip code
Email Address (personal; not school): *
Phone Number: *
Preferred Method of Communication *
Date of Birth: *
mm/dd/yyyy
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Sex: *
Current School: *
Major: *
Year of School: *
Current GPA: *
Estimated Date of Graduation/Date of Graduation *
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YYYY
Have you taken any of the following tests? *
Are you scheduled to take one? If so, which test and what date? *
Are you associated with any of the following? *
Please select one
How did you hear about the Elma Vines Summer Health Academy (EVSHA)? *
What "specialty" (field) are you considering for your career? *
Are you vaccinated? *
What is your Ethnicity *
Household level of Income (immediate family) *
Where do you currently live? *
Family Size (parents/guardian; siblings, include self) *
CV/Resume *
Paste resume below
How do you feel the Summer Health Academy will benefit you? *
500 word Personal Statement
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