MIM Medical Pathway Program (MPP) MCAT Prep w/ Kaplan Fall 2017
All information on the application will remain confidential. Please complete all sections. Applicants will be required to interview prior to acceptance & seat deposit required.
Email address *
First Name *
Last Name *
Street Address (include building & apt #) *
City *
State *
Zip Code *
Cell Phone # *
Home Phone # *
Do you have any allergies? *
If yes, what are you allergic to ?
Birthplace *
Racial/Ethnic Self Identification *
Are you a US citizen ? *
If no, do you have US work authorization documents (VISA Passport)? *
Emergency Contact #1 *
Full Name
Emergency Contact #1 *
Mailing Address
Emergency Contact #1 *
Email Address
Emergency Contact #1 *
Home Phone #
Emergency Contact #1 *
Cell Phone #
College *
Have you had an institutional action? *
Date of Graduation (Expected or Actual) *
Degree *
Overall GPA *
Science GPA *
Other Educational Insitutions
Extracurricular Activites
Summer Activities
Have you completed the following pre-requisites ? *
I have not taken.
1-2 years
2-3 years
4 >
General Chemistry
Organic Chemistry
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 the official AAMC MCAT before
If yes, please indicate date(s) and score(s)
Chem & Phys / CARS / Bio & BioChem / Psychology & Sociology
Health Professional School Application History
Have you applied to HP school before ?
Indicate the year(s) and names of schools *
References that may be contacted. No letters needed. No family please. *
Reference 1 Name, email address, phone (O/H), phone (cell) & relation to applicant
Reference 2 Name, email address, phone (O/H), phone (cell) & relation to applicant
Reference 3 Name, 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.
Mentoring In Medicine Inc. - Background
How did you hear about the program?
Have you participated in other MIM programs ? *
Are you interested in becoming a MIM Teaching Fellow ? *
If yes, which ones? *
100 word essay answering the following questions: (1) Why do you want to be a doctor ? (2) What challenges have you encountered ? *
List links to your social media profiles (LinkedIn FB IG Twitter) *
I understand that upon acceptance to this program, a deposit payment of $50 is expected to hold my seat in the course. Although the full course tuition is $1,750 with scholarship, there may be additional monies/opportunities available to offset my tuition. *
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