The Elma Vines Summer Health Academy 2021
Contact Program Coordinator, contact@vinesmedical.org with any questions or concerns.
*Please send your (1) letter of recommendation via email to: contact@vinesmedical.org
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
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Date of Birth:
mm/dd/yyyy
MM
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DD
/
YYYY
Sex:
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What is your Ethnicity
Current School:
Major:
Year of School:
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Current GPA:
Estimated Date of Graduation/Date of Graduation
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/
DD
/
YYYY
Household level of Income
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Have you taken any of the following tests?
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If so, which test(s) and date(s)?
Are you scheduled to take one? If so, which test and what date?
CV/Resume
Paste resume below
How do you feel the Summer Health Academy will benefit you? *
500 word Personal Statement
Are you associated with any of the following?
Please select one
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How did you hear about EVSHA?
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