Project P.R.E.M.E.D. Program Application 2023

Project Premed Mentoring Program

Question Title

* 1. Name

Question Title

* 2. Gender

Question Title

* 3. Local Address

Question Title

* 4. Permanent Home Address

Question Title

* 5. Primary Phone

Question Title

* 6. Cell Phone Number

Question Title

* 7. Personal Email Address

Question Title

* 8. Personal School Email Address

Question Title

* 9. Birthdate

Question Title

* 10. Contact Person in Case of an Emergency

Question Title

* 11. Contact Person's Number

Question Title

* 12. Highest Level of Education Completed

Question Title

* 13. Anticipated Date of Graduation

Question Title

* 14. Name of College or University

Question Title

* 15. School Address

Question Title

* 16. Race

White

Black or African American

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Other (please specify)

Question Title

* 17. Ethnicity

Hispanic or Latino or Spanish Origin

Not Hispanic or Latino or Spanish Origin

Question Title

* 18. High School Name

Question Title

* 19. High School City

Question Title

* 20. High School State

Question Title

* 21. I intend/plan/would like to enter a health career

Yes

Question Title

* 22. Please select your current Education Status

Rising Freshman

Rising Sophomore

Rising Junior

Rising Senior

Masters

Postbac

Question Title

* 23. What health care field/fields are you interested in?

Question Title

* 24. If you have taken the MCAT, please list your score

Question Title

* 25. Please list your Extra-Curricular Activities.

Question Title

* 26. Please upload your Unofficial Transcript

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

Question Title

* 27. Please upload your Resume

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

Question Title

* 28. A Brief Summary (no more than 100 words) your interest in Project PREMED

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

Question Title

* 29. Proof of US Citizenship or Permanent Residency (Copy of Passport or Birth Certificate and Driver’s License)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

Please send your Letter of support (from university program advisor, professor, or administrator) to Mistie Crowder at stewar21@marshall.edu

Project P.R.E.M.E.D. Program Application 2023

Project Premed Mentoring Program

Question Title

* 1. Name

Question Title

* 2. Gender

Question Title

* 3. Local Address

Question Title

* 4. Permanent Home Address

Question Title

* 5. Primary Phone

Question Title

* 6. Cell Phone Number

Question Title

* 7. Personal Email Address

Question Title

* 8. Personal School Email Address

Question Title

* 9. Birthdate

Question Title

* 10. Contact Person in Case of an Emergency

Question Title

* 11. Contact Person's Number

Question Title

* 12. Highest Level of Education Completed

Question Title

* 13. Anticipated Date of Graduation

Question Title

* 14. Name of College or University

Question Title

* 15. School Address

Question Title

* 16. Race

Question Title

* 17. Ethnicity

Question Title

* 18. High School Name

Question Title

* 19. High School City

Question Title

* 20. High School State

Question Title

* 21. I intend/plan/would like to enter a health career

Question Title

* 22. Please select your current Education Status

Question Title

* 23. What health care field/fields are you interested in?

Question Title

* 24. If you have taken the MCAT, please list your score

Question Title

* 25. Please list your Extra-Curricular Activities.

Question Title

* 26. Please upload your Unofficial Transcript

Question Title

* 27. Please upload your Resume

Question Title

* 28. A Brief Summary (no more than 100 words) your interest in Project PREMED

Question Title

* 29. Proof of US Citizenship or Permanent Residency (Copy of Passport or Birth Certificate and Driver’s License)

Question Title

* 30. T-Shirt Size

Question Title

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

Question Title

* 32. All applications and documentation must be received by May 19, 2023.