* 1. Please provide the following information:

* 2. Gender

* 3. Ethnicity

* 4. Race (select all that apply)

* 5. In what institution are you currently enrolled?

* 6. Hometown at time of high school graduation (City/State)

* 7. College Attended (include City/State)

* 8. Undergraduate Major

* 9. In which kind of community did you grow up? (Select one)

* 10. Currently in which Educational Level

* 11. Currently which Education Status

* 12. Anticipated Date of Graduation

Date:
/
/

* 13. Health Profession Discipline (Select only one)

* 14. Parent/guardian information (optional):

* 15. What type of community would you like to work? (select all that apply)

* 16. l intend/plan/would like to enter a health career in primary care (such as Family Medicine, General Internal Medicine, General Pediatrics, nurse practitioner, or physician assistant, etc.).

* 17. I intend/plan/would like to work with people who are medically underserved or where there is not enough healthcare

* 18. I intend/plan/would like to work in rural areas (not big cities)

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