MIM Summer Medical Pathway Program ~MPP MCAT Prep w/ Kaplan APPLICATION DEADLINE 6/2/15 12 pm noon
All information on the application will remain confidential. Please complete all sections
Full Name
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Mailing Address *
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Email Address *
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Cell Phone # *
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Home Phone # *
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Best way to contact *
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Do you have any allergies? *
Required
If yes, what are you allergic to ?
Your answer
Gender
Legal Residence *
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Birthplace *
Your answer
Racial/Ethnic Self Identification *
Your answer
Are you a US citizen ? *
Required
If no, do you have US work authorization documents (VISA Passport)? *
Required
Emergency Contact *
Full Name
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Emergency Contact *
Date of Birth
MM
/
DD
/
YYYY
Emergency Contact *
Mailing Address
Your answer
Emergency Contact *
Email Address
Your answer
Emergency Contact *
Home Phone #
Your answer
Emergency Contact *
Cell Phone #
Your answer
Best way to contact *
Your answer
Academic Profile *
College
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Date of Graduation *
MM
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DD
/
YYYY
Degree *
Your answer
Overall GPA *
Your answer
Science GPA *
Your answer
Other Education
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Date of Graduation
MM
/
DD
/
YYYY
Degree
Your answer
Overall GPA
Your answer
Science GPA
Your answer
Extracurricular Activites *
Your answer
Summer Activities *
Your answer
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
Your answer
Mentoring In Medicine Inc. - Background *
How did you hear about the program?
Your answer
Who referred you to Mentoring In Medicine ? *
Your answer
Have you participated in other MIM programs ? *
Required
If yes, which ones?
Your answer
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 an Office AAMC MCAT before
If yes please indicate separate scores
PS and date
Your answer
If yes please indicate separate scores
VR and date
Your answer
If yes please indicate separate scores
BS and date
Your answer
If yes please indicate separate scores
WS and date
Your answer
Health Professional School Application History *
Have you applied to medical school before ?
Indicate the year(s) and # of schools *
Your answer
Have you applied to another Health Professional School ? *
Which type
Your answer
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?
Your answer
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
Your answer
*
Reference 2 Name, mailing address, email address, phone (O/H), phone (cell) & relation to applicant
Your answer
*
Reference 3 Name, mailing address, email address, phone (O/H), phone (cell) & relation to applicant
Your answer
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.
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Photo - For application to be considered complete applicants must send an email with photo to mimcoordinator@gmail.com *
I understand that if my photo has not been received my application will not be reviewed
Required
I understand that upon acceptance in this program payment is expected to hold my seat in the course. *
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