CMCA Fall 2013 OpenHouse Registration Form Survey

Thank you for your interest in our annual Fall Open House event of the Icahn School of Medicine and the Graduate School at Mount Sinai. The event will take place on Saturday, October 19, 2013 from 9:30am-3pm in Goldwurm Auditorium. Breakfast and Lunch will be provided.

Please fill in the questions below to register for the event.

You have the option of attending in person, or you can attend via interactive Livestream online. If you plan to attend via Livestream, please indicate that below and a link will be sent to you before the event!

There will be sessions to provide an overview of the medical school admissions process, graduate school admissions process, student life, and financial aid.

Please complete the registration form below to RSVP for this event. If you have any questions, contact CMCA at 212-241-8276 or by email at cmca@mssm.edu.

We look forward to having you join us on October 19th! Please feel free to share this event with a friend!

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1. I plan to attend the open house in person, at the Icahn School of Medicine at Mount Sinai.

Yes

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2. I plan to attend the open house via Livestream (interactive program online).

Yes

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3. First Name: (Required.)

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4. Last Name: (Required.)

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5. Preferred Email Address: (Required.)

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6. Preferred Telephone Number:

(Area Code) ### - ###

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7. Street Address: (Required.)

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8. Apartment:

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9. City: (Required.)

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10. State: (Required.)

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11. Zip: (Required.)

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12. Please mark your current educational status:

Currently in High School

Currently in an Associate Degree program (2 year Community College)

Currently in a Bachelors Degree Program (4 year College/University)

Currently in a Post-Bac program

Currently in a Masters or other graduate degree program

Graduated from a Bachelors or Graduate program and currently working

Other (please specify)

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13. If you are currently in High School, what is the name of your school?

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14. Name of current or last college attended:

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15. What is/was your major in college:

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16. Are you a current applicant to the MD program:

Yes

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17. Are you a current applicant to the graduate school?

Yes

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18. Which of the following programs are you interested in learning more about:

MD Program

PhD Program

MD/PhD Program

MPH Program

P.O.R.T.A.L.(Masters of Science in Clinical Research)/MD Program

Master of Science in Genetic Counseling

Master of Science in Biomedical Sciences

North East Regional Alliance (NERA) MedPREP program

Summer Undergraduate Research Program (SURP)

NIH Postbaccalaureate Research Education Program (PREP) Program

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* 1. I plan to attend the open house in person, at the Icahn School of Medicine at Mount Sinai.

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* 2. I plan to attend the open house via Livestream (interactive program online).

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* 3. First Name: (Required.)

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* 4. Last Name: (Required.)

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* 5. Preferred Email Address: (Required.)

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* 6. Preferred Telephone Number:

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* 7. Street Address: (Required.)

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* 8. Apartment:

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* 9. City: (Required.)

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* 10. State: (Required.)

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* 11. Zip: (Required.)

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* 12. Please mark your current educational status:

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* 13. If you are currently in High School, what is the name of your school?

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* 14. Name of current or last college attended:

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* 15. What is/was your major in college:

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* 16. Are you a current applicant to the MD program:

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* 17. Are you a current applicant to the graduate school?

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* 18. Which of the following programs are you interested in learning more about:

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* 19. Please tell us how you heard about the CMCA Fall Open House event:

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* 20. Please tell us how you heard about the Icahn School of Medicine at Mount Sinai:

1. I plan to attend the open house in person, at the Icahn School of Medicine at Mount Sinai.

2. I plan to attend the open house via Livestream (interactive program online).

3. First Name: (Required.)

4. Last Name: (Required.)

5. Preferred Email Address: (Required.)

6. Preferred Telephone Number:

7. Street Address: (Required.)

8. Apartment:

9. City: (Required.)

10. State: (Required.)

11. Zip: (Required.)

12. Please mark your current educational status:

13. If you are currently in High School, what is the name of your school?

14. Name of current or last college attended:

15. What is/was your major in college:

16. Are you a current applicant to the MD program:

17. Are you a current applicant to the graduate school?

18. Which of the following programs are you interested in learning more about:

19. Please tell us how you heard about the CMCA Fall Open House event:

20. Please tell us how you heard about the Icahn School of Medicine at Mount Sinai: