Dr. Rubin's Mini Medical School Summer Experience Program Application
The Mini Medical School Summer Experience program is an eight hour program that provides an overview of medical school with an emphasis on clinical information. The students hear lectures for three hours and then given a lunch break. We then lecture for an additional hour before breaking up into groups that rotate through 17 stations. Each station, or “experience,” is staffed with one or more trained Teaching Assistants who explain and walk you through the "experience" before you do it. The program then ends with a 30 minute lecture on healthcare professions, schools and admissions. This program is appropriate for any student interested in a career in healthcare and is either in high school or college (high school entering freshman or above).
We are offering the program twice this summer. Once on Saturday June 27th and a second time Sunday June 28th.
The program will be held at the Edward - Plainfield ER Conference Rooms located at 24600 W. 127th Street, Plainfield, IL 60585 from 9:30 AM to 5:30 PM. Plan on picking up your student at 5:45 PM. at the Cancer just west of the ER entrance
Our application process is simple and has 3 steps:
Step 1 - Submit this form online. Once received an automatic email will be sent to you with a consent form.
Step 2 - Print and complete the consent form.
Step 3 - Mail your signed consent form along with your program fee of $200 to us. At this time, we do not accept credit cards Thus the best payment is by check.
Applicants are accepted on a first come first served basis once we receive your online application, your parent permission form and your program fee.
Once we accept you, if for any reason your plans change and you notify us by email on or before June 1, 2020 we will refund you $150.00 . Complete applications received on or after June 1, 2020 are non-refundable.
What is your name?
Print your legal name - Not a nickname - Both First Name and Last Name ** this is how your name will appear on your certificate. PLEASE CHECK YOUR SPELLING
Which day do you want to attend?
We offer identical programs on Saturday and Sunday - No preference gives you a better chance of acceptance.
Saturday June 27
Sunday June 28
What is your phone number?
What number should we call if we need to contact you?
What is your email?
Where should we send information? Please double check your spelling for accuracy.
What is your address?
Please indicate your full address including street number, street, city, state and zip code
What grade are you currently in?
Middle School Senior (8th Grade)
High School Freshman (9th Grade)
High School Sophomore (10th Grade)
High School Junior (11th Grade)
High School Senior (12th Grade)
What is the name of your school?
What is your t-shirt size?
What is your GPA?
If you don't know or have an official GPA, please provide your best estimate.
Is there anything you need to tell us? For example - do we need to know that you are allergic to something or need to leave early or arrive late?
Please provide the name of a parent (First and Last Name)
Please provide the email of your parent
Please provide a phone number for your parent
DIGITAL SIGNATURE: By typing in your name you hereby indicate that the information provided is accurate to the best of your ability.
A student or parent may sign.
Once all required fields are completed you will be able to press the submit button to send us your initial application. This form will not send if all fields are not completed. A message will pop up once the form is saved. If you don't see that message, you have not completed all required fields. The pop up message has a link for you to download your parent permission form. Print the form and mail it to us with the program fee. It is your responsibility to make sure we get the parent consent and program fee. Please keep in mind that we will accept students on a first come first served basis. Submitting this form does not guarantee we have space for you. We will email you once we get the parent form and program fee. Once received, we will confirm your acceptance into the program.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service