GIMSPP Student Application Summer 2023

*IF YOU APPLY FOR THE GIMSPP 2023 PROGRAM AFTER 2/28/23 YOU WILL BE PLACED ON OUR WAITLIST AND WE WILL BE IN CONTACT IF WE ARE ABLE TO MATCH*

Mandatory fields must be filled out or your application will be considered incomplete.

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* 1. Please enter your contact information.

We communicate primarily through email so please ensure the emails below are ones you check regularly.

Name

Address (List current address info while at school)

City

State

Zip Code While at School

Personal Email Address

School Email Address

Phone Number

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* 2. Please list your permanent address below. This is where we will send applicable program documents so please be sure it is accurate

Permanent Address 1

Permanent Address 2

Permanent City/Town

Permanent State/Province

Permanent ZIP/Postal Code

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* 3. Which medical school are you enrolled in? Please note: You must be currently enrolled in a Texas medical school in order to apply for the program.

BCM - Baylor College of Medicine

PLFSOM - Texas Tech University Health Sciences Center Paul L. Foster School of Medicine

SHSUCOM - Sam Houston State University College of Osteopathic Medicine

TAMUHSC - Texas A&M Health Science Center College of Medicine

UNTHSC School of Medicine at Fort Worth

TTUHSC - Texas Tech University Health Sciences Center School of Medicine

UHCOM - University of Houston College of Medicine

UIWSOM - University of the Incarnate Word School of Osteopathic Medicine

UNTHSC - University of North Texas Health Science Center at Fort Worth/Texas College of Osteopathic Medicine

UTDell - The University of Texas at Austin-Dell Medical School

UTHealth - The University of Texas Health Science Center at Houston McGovern Medical School

UTHSCSA - The Joe R. and Teresa Lozano Long University of Texas School of Medicine at San Antonio

UTMB - The University of Texas Medical Branch at Galveston

UTRVG - The University of Texas Rio Grande Valley Medical School

UTSW - The University of Texas Southwestern Medical Center

TCU - Burnett School of Medicine

EnMed -TAMU

UT Tyler School of Medicine

Other (please specify)

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* 4. Please Upload a copy of your student ID.

PDF, PNG, JPG, JPEG file types only.

Choose File

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* 5. Year of Medical School?

First

Second

Third

Fouth

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* 6. Anticipated Graduation Date (year)?

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* 7. Name of Faculty Director/Advisor? (please provide the name of a faculty member at your institution who could be contacted regarding your participation in this preceptorship if the need arises)

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* 8. Email address of Faculty Director/Advisor? (please provide the email of a faculty member at your institution who could be contacted regarding your participation in this preceptorship if the need arises)

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* 9. In what field do you intend to practice medicine?

Internal Medicine

Subspeciality

Undecided

Other (please specify)

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* 10. Do you speak language(s) other than English? Please choose all that apply

Arabic

French

Hindi

Mandarin

Spanish

Vietnamese

None

Yes, other

GIMSPP Student Application Summer 2023

Question Title

* 1. Please enter your contact information.We communicate primarily through email so please ensure the emails below are ones you check regularly.

Question Title

* 2. Please list your permanent address below. This is where we will send applicable program documents so please be sure it is accurate

Question Title

* 3. Which medical school are you enrolled in? Please note: You must be currently enrolled in a Texas medical school in order to apply for the program.

Question Title

* 4. Please Upload a copy of your student ID.

Question Title

* 5. Year of Medical School?

Question Title

* 6. Anticipated Graduation Date (year)?

Question Title

* 7. Name of Faculty Director/Advisor? (please provide the name of a faculty member at your institution who could be contacted regarding your participation in this preceptorship if the need arises)

Question Title

* 8. Email address of Faculty Director/Advisor? (please provide the email of a faculty member at your institution who could be contacted regarding your participation in this preceptorship if the need arises)

Question Title

* 9. In what field do you intend to practice medicine?

Question Title

* 10. Do you speak language(s) other than English? Please choose all that apply

* 1. Please enter your contact information.

We communicate primarily through email so please ensure the emails below are ones you check regularly.