MIM Community Health Ambassador Program Application Fall 2017 Deadline 10/18/17
All information on the application will remain confidential. Please complete all sections
Email address
First Name:
Your answer
Last Name:
Your answer
Street Address (include Building & Apt #)
What is your home address?
Your answer
City:
Your answer
State:
Your answer
Zip Code:
Your answer
Cell Phone #
Your answer
Home Phone #
Your answer
Racial/Ethnic Self Identification
Your answer
Gender
DOB
Applicant's Date of Birth
MM
/
DD
/
YYYY
Birthplace
City, State, Country
Your answer
Are you a US citizen ?
If you are not a US citizen, do you have US work authorization documents (VISA Passport)?
Do you have any allergies?
If yes, what allergy?
Your answer
Do you have a car ?
Do you have a state issued valid driver's license ?
Emergency Contact (EC) Name-#1
Full Name
Your answer
EC #10 E-mail
Emergency Contact - Email Address
Your answer
EC #1 Home Phone
Emergency Contact - Home Phone #
Your answer
EC#1- Cell Phone
Emergency Contact - Cell Phone #
Your answer
High School
Academic Profile - What educational institution do/did you attend?
Your answer
High School
City & State (School Address)
Your answer
College
Your answer
Post-baccalaureate/Graduate
Your answer
Current Educational Institution-Date of Graduation
Expected Graduation Date? Or, when did you graduate?
MM
/
DD
/
YYYY
Degree (College and/or Graduate School)
Your answer
Overall GPA at Current Institution
Your answer
Extracurricular Activites
Your answer
Summer Activities
Your answer
How did you hear about the program?
Your answer
Other MIM programs?
Have you participated in other MIM programs?
If yes, which ones?
Are you interested in becoming an MIM Teaching Fellow
History / Record
Have you ever been charged or convicted of a misdemeanor, felony or crime?
Health Profession of Interest
Health Professional School Application History
Have you applied to medical school before ?
Indicate the year(s) and # of schools
Your answer
References may be contacted. No letters needed. No family please.
Reference 1- Name, phone number & relation to applicant
Your answer
References may be contacted. No letters needed. No family please.
Reference 2- Name, phone number & relation to applicant
Your answer
References may be contacted. No letters needed. No family please.
Reference 3- Name, phone number & relation to applicant
Your answer
Press Release
In exchange for consideration received, I hereby give permission to Mentoring In Medicine Inc. to use my name and photographic likeness in all forms and media advertising, trade and any other lawful purposes.
List links to your social media profiles (LinkedIn FB IG Twitter)
Your answer
In a 100 word essay answer the following questions: Why do you want to be a health professional ? What challenges have you encountered ?
Your answer
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