Dr. Rubin's Summer Mini Medical School Experience Program Application
The Mini Medical School 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 four hours and are then broken up into groups that rotate through 16 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 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).

The program will be held at the Edward - Plainfield ER Conference Rooms located at 24600 W. 127th Street, Plainfield, IL 60585 on Saturday June 23, 2018 and repeated on Sunday June 24, 2018 from 9:30 AM to 5:30 PM.

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.

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, 2018 we will refund you $150.00 . Complete applications received after June 1 are non-refundable.

We are running identical programs on Saturday June 23 and Sunday June 24, 2018. Please indicate which day you want to attend. * No preference allows us to place you where we have space and has a greater chance of acceptance. *
What is your name? *
Print your legal name - Not a nickname - Both First Name and Last Name
Your answer
What is your phone number? *
What number should we call if we need to contact you?
Your answer
What is your email? *
Where should we send information? Please double check your spelling for accuracy.
Your answer
What is your address? *
Please indicate your full address including street number, street, city, state and zip code
Your answer
What grade are you currently in? *
What is the name of your high school or college? *
Your answer
What is your t-shirt size? *
What is your GPA? *
If you don't know your official GPA, please provide your best estimate.
Your answer
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? Do you want to mention something about yourself?
Your answer
Please provide the name of a parent (First and Last Name) *
Your answer
Please provide the phone number of your parent. *
Your answer
Please provide the email of your parent *
We will send all communications to you and your parent.
Your answer
DIGITAL SIGNATURE: By typing in your name you hereby indicate that the information provided is accurate to the best of your ability. *
A parent or student can sign this applicaton.
Your answer
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 if the form is received. 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.
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