Dr. Rubin's Summer Mini Medical School Experience Program Application
The Mini Medical School Experience program is an eight hour program that provides an overview of medical school with an emphasis on clinical information. The students hear lectures for four hours and are then broken up into groups that rotate through 15 stations. Each station, or “experience,” is staffed with a trained Mini Medical School Teaching Assistant. The program then ends with a lecture on healthcare schools and admissions. This program is appropriate for any student interested in a career in healthcare and is either in high school or college (high school entering freshman or above).

The program will be held at the Edward - Plainfield ER Conference Rooms located at 24600 W. 127th Street, Plainfield, IL 60585 on Saturday June 24, 2017 and repeated on Sunday July 23, 2017 from 9:30 AM to 5:30 PM.

Our application process has 3 steps:
Step 1 - Submit this form online. Once received we will email you a consent form.
Step 2 - Print and complete the consent form.
Step 3 - Mail your signed consent form along with your program fee of $200 to us.

Applicants are accepted on a first come first served basis once we receive your online application, your parent permission form and your program fee.

*** As of June 1, 2017 the Saturday June 24 th program is full. There are a few spots left in the July 23 program. If you can not attend July 23rd, we can put you on a waiting list for the June 23rd program. If for any reason a student can not attend that program, we will contact students on the waiting list in the order they applied.

Once we accept you, if for any reason your plans change and you notify us by email on or before June 1, 2017 we will refund you $150.00 . Complete applications received after June 1 are non-refundable.

We are running identical programs on Saturday June 24 and Sunday July 23, 2017. Please indicate your preference from the list below. *As of May 21 the June program is almost full.
What is your name?
Print your legal name - Not a nickname - Both First Name and Last Name
Your answer
What is your phone number?
What number should we call if we need to contact you?
Your answer
What is your email?
Where should we send information? Please check your email regularly.
Your answer
What is your address?
Please indicate your full address including street number, street, city, state and zip code
Your answer
What grade are you currently in?
What is the name of your high school or college?
Your answer
What is your t-shirt size?
What is your GPA?
If you don't know your official GPA, please provide your best estimate.
Your answer
Is there anything you need to tell us? For example - do we need to know that you are allergic to something or need to leave early or arrive late? Do you what to mention something about yourself?
Your answer
Please provide the name of a parent (First and Last Name)
Your answer
Please provide the phone number of your parent.
Your answer
Please provide the email of your parent
We will send all communications to you and your parent.
Your answer
DIGITAL SIGNATURE: By typing in your name you hereby indicate that the information provided is accurate to the best of your ability.
A parent or student can sign this applicaton.
Your answer
Instructions
Once all required fields are completed you will be able to press the submit button to send us your initial application. This form will not send if all fields are not completed. A message will pop up if the form is received. If you don't see that message, you have not completed all required fields. The pop up message has a link for you to download your parent permission form. Print the form and mail it to us with the program fee. It is your responsibility to make sure we get the parent consent and program fee. Please keep in mind that we will accept students on a first come first served basis. Submitting this form does not guarantee we have space for you. We will email you once we get the parent form and program fee.
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