Emergency Department Clinical Exposure & Mentoring Program ~ MIM ED-CEMP Fall 2017
All information on the application will remain confidential. Please complete all sections
Email address *
First Name *
Your answer
Last Name *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Cell Phone # *
Your answer
Do you have any allergies? *
Required
If yes, what are you allergic to ?
Your answer
Gender
Birthplace *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Racial/Ethnic Self Identification *
Your answer
Are you a US citizen ? *
Required
If no, do you have US work authorization documents (VISA, Passport)? *
Required
Emergency Contact *
Full Name
Your answer
Emergency Contact #1 *
Email Address
Your answer
Emergency Contact #1 *
Home Phone #
Your answer
Emergency Contact #1 *
Cell Phone #
Your answer
Emergency Contact #2 *
Full Name
Your answer
Emergency Contact #2 *
Email Address
Your answer
Emergency Contact #2 *
Home Phone #
Your answer
Emergency Contact #2 *
Cell Phone #
Your answer
Emergency Contact #3 *
Full Name
Your answer
Emergency Contact #3 *
Email Address
Your answer
Emergency Contact #3 *
Home Phone #
Your answer
Emergency Contact #3 *
Cell Phone #
Your answer
College Include City & State *
Your answer
Date of Graduation Expected or Actual *
MM
/
DD
/
YYYY
Degree *
Your answer
Overall GPA *
Your answer
Science GPA *
Your answer
Date of Graduation Expected or Actual *
MM
/
DD
/
YYYY
Overall GPA *
Your answer
Science GPA *
Your answer
Extracurricular Activites
Your answer
Summer Activities
Your answer
Mentoring In Medicine Inc. - Background *
How did you hear about the program?
Your answer
Have you participated in other MIM programs ? *
Required
If yes, which ones? *
Are you interested in becoming a Teaching Fellow ? *
Required
History / Record *
Have you ever been charged or convicted of a misdemeanor, felony or crime?
Health Profession of Interest *
References may be contacted. No letters needed. No family please.
Reference 1 Name, email address, phone (O/H), phone (cell) & relationship to applicant
Your answer
Reference 2 Name, email address, phone (O/H), phone (cell) & relationship to applicant
Your answer
Reference 3 Name, email address, phone (O/H), phone (cell) & relationship 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 your social medial profiles (LinkedIn FB IG Twitter) *
Your answer
100 word essay answering the following questions:(1) Why do you want to be a health professional ? (2) What challenges have you encountered ? *
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms