2018 MIM Community Health Ambassador and Mentoring Program (Deadline 12-30-17)

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All information on the application will remain confidential. Please complete all sections

First Name: *

Last Name: *

Street Address (include Building & Apt #) *

What is your home address?

City: *

State: *

Zip Code: *

Cell Phone # *

Home Phone # *

Racial/Ethnic Self Identification *

Gender *

Male

Female

DOB *

Applicant's Date of Birth

YYYY

Birthplace *

City, State, Country

Are you a US citizen ? *

Yes

If you are not a US citizen, do you have US work authorization documents (VISA Passport)? *

Yes

Does Not Apply

Do you have any allergies? *

Yes

If yes, what allergy?

Do you have a car ? *

Yes

Do you have a state issued valid driver's license ? *

Yes

Emergency Contact (EC) Name-#1 *

Full Name

EC #10 E-mail *

Emergency Contact - Email Address

EC #1 Home Phone *

Emergency Contact - Home Phone #

EC#1- Cell Phone *

Emergency Contact - Cell Phone #

High School *

Academic Profile - What educational institution do/did you attend?

High School *

City & State (School Address)

College

Post-baccalaureate/Graduate

Current Educational Institution-Date of Graduation *

Expected Graduation Date? Or, when did you graduate?

YYYY

Degree (College and/or Graduate School)

Overall GPA at Current Institution *

Extracurricular Activites

Summer Activities

How did you hear about the program? *

Other MIM programs? *

Have you participated in other MIM programs?

Yes

If yes, which ones? *

Empowerment Seminar

Teaching Fellows / School Based Programs

Community Health Ambassador Program

Emergency Department Clinical Exposure & Mentoring Program

In School Program (ISP HS)

After School Program (ASP MS, HS)

Other:

Are you interested in becoming an MIM Teaching Fellow *

Yes

History / Record *

Have you ever been charged or convicted of a misdemeanor, felony or crime?

Yes

Health Profession of Interest *

Health Professional School Application History *

Have you applied to medical school before ?

Yes, once

Yes, twice

Yes, 3 or more

Indicate the year(s) and # of schools *

References may be contacted. No letters needed. No family please. *

Reference 1- Name, phone number & relation to applicant

References may be contacted. No letters needed. No family please. *

Reference 2- Name, phone number & relation to applicant

References may be contacted. No letters needed. No family please. *

Reference 3- Name, phone number & relation to applicant

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.

I agree

I disagree

List links to your social media profiles (LinkedIn FB IG Twitter) *

In a 100 word essay answer the following questions: Why do you want to be a health professional ? What challenges have you encountered ? *

Submit

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