MIM Medical Pathway Program (MPP) MCAT Prep w/ Kaplan Fall 2017 Application Deadline 10/18/17
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?
Required
If yes, what are you allergic to ?
Gender
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 #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)
MM
/
DD
/
YYYY
Degree
Overall GPA
Science GPA
Other Educational Insitutions
Extracurricular Activites
Summer Activities
Have you completed the following pre-requisites ?
I have not taken.
Currently
1-2 years
2-3 years
4 >
Biology
Physics 
General Chemistry
Organic Chemistry
Psycology
Sociology
Biochemistry
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 ?
Required
Are you interested in becoming a MIM Teaching Fellow ?
Required
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.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Additional Terms