PHC Board Medical Student Representative Application

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* 1. Name and Contact Info:

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Cell Phone Number

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* 2. Race/Ethnicity (Check all that apply. For outreach and reporting purposes only.):

American Indian/Alaska Native

Asian/Pacific Islander

Black or African American

Hispanic or Latino

White, Non Hispanic, Non Latino

Prefer Not to Answer

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* 3. What is your gender?

Female

Male

Transgender-male to female

Transgender-female to male

Non-Binary (neither male nor female)

Another Gender Identity

Prefer Not to Answer

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* 4. Languages Spoken (Check all that apply. For outreach and reporting purpose only.):

Arabic

Armenian

Catonese

English

Farsi

Hmong

Japanese

Khmer

Korean

Mandarian

Punjabi

Russian

Spanish

Swahili

Tagalog

Vietnamese

Other/multiple languages (please specify)

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* 5. High School:

Name

City

State

Zip Code

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* 6. Community College (If applicable):

Name

City

State

Zip Code

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* 7. Undergraduate College (Institute where you obtained your undergraduate degree):

Name

City

State

Zip Code

Graduation Year

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* 8. Medical School:

Name

City

State

Zip Code

Anticipated Graduation Year

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* 9. Specialty Interest. (If known)

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* 10. PHC's mission is to improve community health, diversify the physician workforce and expand access to care. How will you contribute to this mission if you are selected?

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* 11. Please list any organizations that you are or have recently been active in and any leadership role(s) held.

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* 12. Interviews will be held on Wednesday, November 6. Please rate the following time options by preference.

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* 13. Please upload a CV or Resume here:

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