Pre-Health Dreamers Intake Form Survey

PHD wants to keep connect with you!

The following intake will help the Pre-Health Dreamers team, as we gather resources and create our webinars and projects. This intake will also help us as we strengthen our network.

Expect resources to be shared with you, such as general information, posting about internship/volunteer/employment opportunities, and relevant current event news. Additionally, newsletters will provide updates on our ongoing projects and advocacy efforts.

This information will be treated with utmost confidentiality.

Thank you,
PHD

1.First Name

2.Last Name

3.E-mail address

4.Confirm E-mail address

5.School Name (Enter the name of the school you are currently attending, last attended, or are affiliated with if you are an educator.

6.Where do you currently live? (City, State)

8.What type of career are you interested in? (Mark only one)

Medicine

Research (Master's/PHD)

Physician-Scientist (MD-PhD)

Nursing

Dentistry

Pharmacy

Pubic Health (Health Education, Community Health, Policy etc)

Mental Health (Psychology, Psychiatry, Social Work etc.)

Allied Health (Physician Assistant, Administration, Info Management, Dietetics, Physical Therapy, etc.)

Other (please specify)

9.How did you hear about us?

Social Media (FB, Instagram, Twitter)

Friend

Educator

School

Other (please specify)

10.Do you have any questions, comments, or ideas that you would like to bring to our attention?

11.Please select the option that best matches you?

Undocumented

Ally

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