Program Application – Welcome Students!

Organization ID#:(Are you applying for a program reserved by an organization/group? If so, enter the organization’s Group ID# here.)

Affiliation to any student organization or group?

Which program are you applying for? (program dates)*

First Name *

Middle Name

Last Name *

Email Address *

Phone *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Date of Birth *

SelectAre you a U.S. Citizen or have permanent residence in the U.S.?*

Have you previously attended any other medical mission trips? *YesNo

Parent/guardian information

First Name *

Last Name *

Relationship *

Phone *

Email Address *

What languages do you speak? *

Are you a first-generation college student? *YesNo

Select List any awards, honors, certifications, medical experiences, etc.: *

High School Name: *

Graduation Year: *

Address:

Name of Undergraduate Institution *

Dates of Attendance:* *

Street Address

City

State/Province

ZIP / Postal Code

Country

Major: *

Minor:

Degree Pursued/Earned: *

Degree Pursued/Earned: Expected Graduation Year:*

Overall GPA: *

Career Plans:* *Career Plans:* [Undecided, Medicine, Pharmacy, Physician Assistant, Nursing, Medical Research, etc.]

Essay

Why are you interested in applying to a Hands on Medical Training Program? *

Resume *

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Unofficial Transcript *

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Comments

Credit / Debit Card *

Save as Draft

Student Application