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Health Care Pathway Initiative

June 5, 2023 - June 29, 2023

This is a 4 week program.  Please do not apply to the program if you cannot attend each day for the entire 4 weeks.

Information for this form is provided voluntarily. Joan C. Edwards School of Medicine Office of Diversity and
Inclusion is required to report information about program participants. Data will be kept private to the extent
allowed by law and will be referenced periodically to evaluate the effectiveness of the Office of Diversity and
Inclusion services and programs. We appreciate your cooperation in the completion of this form.

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* 1. Students Name

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* 2. Home Address

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* 3. City, State, and Zip Code

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* 4. Student's Email address

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* 5. Student's Cell Phone Number

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* 6. Gender

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* 7. Birthdate

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* 8. Race

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* 9. Ethnicity

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* 10. Name of High School 

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* 11. High School Address

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* 12. High School Counselor's Name

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* 13. High School Counselor's phone number?

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* 14. High School Counselor's Email Address

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* 15. Please Select your Current High School Status

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* 16. Graduation Date

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* 17. Please select any Math classes you completed during your Freshman year

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* 18. Please select the Math classes you completed during your Sophomore year

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* 19. Please select any Math Classes you completed during your Junior year

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* 20. Please select the Math Classes are taking during your Senior Year

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* 21. What interests you the most:  Math, Science, Technology, Engineering, or another subject?  Why?

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* 22. Why should you be selected to attend summer Health Care Pipeline Initiative?

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* 23. What is your favorite subject and why?

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* 24. What is your least favorite subject and why?

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* 25. If you could learn anything(related to science, technology, engineering, mathematics, and/or healthcare) what would it be and why?

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* 26. Family Information:  Mother/Guardian

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* 27. Please Select their Highest Level of Education Completed

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* 28. Family Information:  Father/Guardian

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* 29. Please Select their Highest Level of Education

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* 30. Please Check/All of the Following if they Pertain to you

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* 31. Please select your t-shirt size

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* 32. Please list any food allergies and/or dietary restrictions

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* 33. Parent Signature

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* 34. Date

Date

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* 35. Student signature

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* 36. Date

Date

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* 37. Please upload your Unofficial Transcript

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File
Please request your W9, Photography Form, and Media Form by emailing Mistie Crowder at stewar21@marshall.edu.  These must be received as part of the application process.  We will not process your application until we receive all documents required.
Please have your letter of recommendation directly emailed to Mistie Crowder at stewar21@marshall.edu
Applications and all Documents must be completed and received by May 12, 2023
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