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 and is confidential.
This year, due to the pandemic, we are not requiring teacher recommendations and we are accepting students on a rolling basis. Meaning the sooner we get this form, the sooner the student gets a response.
Thank You for your support and advice to future physicians.
Ira S Rubin, M.D., Ph.D.
Founder and Creator of
Dr Rubin's Mini Medical School
A 501C3 private foundation
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Please print the student's name.
First Name and Last Name - Do not use a nick name.
Please print the student's email address
Please print the student's phone number
Please print the name of your high school.
Please verify the student's grade?
Please note, we do not accept high school freshman.
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
or faxed to 888-725-0506. Please state in the space below if you emailed or faxed a transcript.
What is the highest GPA in this student's class?
What is your name?
Print the name of the school counselor submitting this form.
What is your official school email? We will use this email to contact you if a question arises.
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.
I hereby declare that I am the counselor named above
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