MIM Summer 2016 Emergency Department Clinical Exposure & Mentoring Program ~ ED CEMP APPLICATION

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

All information on the application will remain confidential. Please complete all sections

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? *

yes

Required

If yes, what are you allergic to ?

Gender

Male

Female

Legal Residence *

Birthplace *

Racial/Ethnic Self Identification *

Are you a US citizen ? *

Yes

Required

If no, do you have US work authorization documents (VISA Passport)? *

Yes

Required

Emergency Contact *

Full Name

Emergency Contact *

Date of Birth

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 *

YYYY

Degree *

Overall GPA *

Science GPA *

Other Education

Date of Graduation

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 ? *

Yes

Required

If yes, which ones?

History / Record *

Have you ever been charged or convicted of a misdemeanor, felony or crime?

Yes

Health Profession of Interest *

MCAT History & Preparation *

Have you taken an Office AAMC MCAT before

Yes, once

Yes, twice

Yes, thrice

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 ?

Yes, once

Yes, twice

Yes, 3 or more

Indicate the year(s) and # of schools *

Have you applied to another Health Professional School ? *

Yes

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.

I agree

I disagree

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

YES

Required

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms