STUDENT INFORMATION

Please complete this form to participate in the GI Track Shadowing Program. Students must be 16 years or older to participate.

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* 1. Student Name

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* 2. Student Preferred/Chosen Name (optional)

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* 3. Student Pronouns (optional)

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* 4. Student Date of birth

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* 5. Student Address

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* 7. Student Phone

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* 8. What school will the student attend in the Fall of 2026?

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* 9. What grade/year will the student attend in the Fall of 2026?

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* 10. For students 18+, are you currently enrolled in a pre-med program, nursing undergraduate program or medical school?

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* 11. What days is the student usually available? (Select all that apply.)

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* 12. Are there any dates in June - August 2026 when the student will be unavailable to shadow?

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* 13. Below is a list of locations for shadowing experiences. Please rank them in order of preference, with #1 being the most preferred location and #9 being the least preferred location.

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