MIM Summer 2016 Emergency Department Clinical Exposure & Mentoring Program ~ ED CEMP APPLICATION
All information on the application will remain confidential. Please complete all sections
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Mailing Address *
Example: 1234 Maple Drive Apt 3, Sunnyside NY 10001
Full Name
Cell Phone # *
Home Phone # *
Email Address *
Best way to contact *
Do you have any allergies? *
Required
If yes, what are you allergic to ?
Gender
Legal Residence *
Birthplace *
Racial/Ethnic Self Identification *
Are you a US citizen ? *
Required
If no, do you have US work authorization documents (VISA Passport)? *
Required
Emergency Contact *
Full Name
Emergency Contact *
Date of Birth
MM
/
DD
/
YYYY
Emergency Contact *
Mailing Address
Emergency Contact *
Email Address
Emergency Contact *
Home Phone #
Emergency Contact *
Cell Phone #
Best way to contact *
Academic Profile *
College
Date of Graduation *
MM
/
DD
/
YYYY
Degree *
Overall GPA *
Science GPA *
Other Education
Date of Graduation
MM
/
DD
/
YYYY
Degree
Overall GPA
Science GPA
Extracurricular Activites *
Summer Activities *
Have you completed the following pre-requisites ? *
Taken Course 
Currentlty
1-2 years 
2-3 years 
4 >
Row 1
Biology
Physics 
General Chemistry
Organic Chemistry
Mentoring In Medicine Inc. - Background *
How did you hear about the program?
Who referred you to Mentoring In Medicine ? *
Have you participated in other MIM programs ? *
Required
If yes, which ones?
History / Record *
Have you ever been charged or convicted of a misdemeanor, felony or crime?
Health Profession of Interest *
MCAT History & Preparation *
Have you taken an Office AAMC MCAT before
If yes please indicate separate scores
PS and date
If yes please indicate separate scores
VR and date
If yes please indicate separate scores
BS and date
If yes please indicate separate scores
WS and date
Health Professional School Application History *
Have you applied to medical school before ?
Indicate the year(s) and # of schools *
Have you applied to another Health Professional School ? *
Which type
Please complete the following essay in no more than 100 words. Answer the question to the best of your ability. *
Why do you want to be a health professional? What challenges have you encountered?
References may be contacted. No letters needed, No family please *
Reference 1 Name, mailing address, email address, phone (O/H), phone (cell) & relation to applicant
*
Reference 2 Name, mailing address, email address, phone (O/H), phone (cell) & relation to applicant
*
Reference 3 Name, mailing address, email address, phone (O/H), phone (cell) & relation to applicant
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.
Photo - For application to be considered complete applicants must send an email with photo to info@medicalmentor.org  *
I understand that if my photo has not been received my application will not be reviewed
Required
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