Dr Rubin's Mini Med School Counselor Form
If you are the school counselor of a student applying to Dr. Rubin's Mini Medical School for High School Students program, you may use this online form. This form is not for students or parents.

Please fill out all required fields (marked with a red *). The form will only submit once all required fields are completed. Once submitted a pop up message will confirm that the information is accepted. Our student application deadline is October 31 but we will accept online recommendations August until November 7th. We will only accept a recommendation from an official school email address. The purpose of this form is to confirm the applicants enrollment
and academic performance.

This form will only be accepted when submitted from an official school email account. The information provided will not be shared

The student application deadline is Oct 31, 2019. The deadline to submit this counselor form online is November 7, 2019.
Please print the student's name. *
First Name and Last Name - Do not use a nick name.
Your answer
Please print the student's email address
Your answer
Please print the student's phone number
Your answer
Please print the name of your high school. *
Your answer
Please verify the student's grade? *
Please note, we do not accept high school freshman.
What is the highest GPA in this student's class?
Your answer
What is this student's GPA? *
If your school does not calculate a GPA, please provide an unofficial GPA or the student's transcript. The transcript can be emailed to rubinminimedicalschool@gmail.com or faxed to 888-725-0506. Please state in the space below if you emailed or faxed a transcript.
Your answer
What is your name? *
Print the name of the school counselor submitting this form.
Your answer
Digital Signature
By checking this box, you are confirming that you are the counselor submitting this form. After submitting this form, you will get a confirmation on your official school email.
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