Emergency Department Clinical Exposure & Mentoring Program ~ MIM ED-CEMP Fall 2017 Application 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
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
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