MADI APPLICATION
Please complete this application in its entirety. There are only 30 spaces available for this program.

Demographic Information

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* 1. First Name

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* 2. Last Name

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* 3. Home Address

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* 4. Campus Address (if known)

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* 5. Gender (Please select one, or write in your preference)

Female

Male

Trans*

Self-Identify:

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* 6. Ethnicity (if bi/multi-racial, please choose more than one)

African American/Black

Asian American

Arab American

Caucasian

Native American

Hispanic/Latino

Not listed (please specify)

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* 7. What is your MSU NetID email address?

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* 8. What is an alternate email address to reach you?

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* 9. What is your cell phone number?

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* 10. Are you a U.S. citizen?

Yes

If no, please list your home country

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* 11. Annual Family Income (if you are unsure, please estimate) - select one:

Less than $40,000

$40,000-$60,000

$60,000-$80,000

$80,000-$100,000

$100,000 or more

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* 12. Religious Affiliation (If more than one religion is practiced in your household, please select more than one):

Atheist

Agnostic

Buddhist

Hindu

Jewish

Muslim

Christian

Catholic

No religious affiliation

Not listed (please specify)

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* 13. Will you need any health related accommodations? (if yes, please describe below)

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* 14. What is the highest level of education completed by your father?

Less than high school

High school/GED

Some College

2-Year college degree/Trade school

4-Year college degree

Master's degree

Doctoral degree

Professional degree (MD, JD, etc.)

Unsure

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* 15. What is the highest level of education completed by your mother?

Less than high school

High school/GED

Some College

2-Year college degree/Trade school

4-Year college degree

Master's degree

Doctoral degree

Professional degree (MD, JD, etc.)

Unsure

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* 16. What type of school did you attend?

Rural

Urban/Inner city

Suburban

Home schooled

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* 17. How diverse was your high school?

Little to no diversity

Some diversity

Very diverse

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* 1. First Name

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* 2. Last Name

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* 3. Home Address

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* 4. Campus Address (if known)

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* 5. Gender (Please select one, or write in your preference)

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* 6. Ethnicity (if bi/multi-racial, please choose more than one)

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* 7. What is your MSU NetID email address?

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* 8. What is an alternate email address to reach you?

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* 9. What is your cell phone number?

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* 10. Are you a U.S. citizen?

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* 11. Annual Family Income (if you are unsure, please estimate) - select one:

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* 12. Religious Affiliation (If more than one religion is practiced in your household, please select more than one):

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* 13. Will you need any health related accommodations? (if yes, please describe below)

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* 14. What is the highest level of education completed by your father?

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* 15. What is the highest level of education completed by your mother?

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* 16. What type of school did you attend?

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* 17. How diverse was your high school?

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* 18. What is the name and location of your high school?