Honors Program for Rural and Urban Underserved Primary Care Medicine

Part 1: APPLICANT INFORMATION

Date *

Name *

First Last

Email *

Phone *

Permanent Address *

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Ethnicity *

Hispanic/Latino
Non Hispanic/Latino
Not Reported

Veteran Status *

No Military Service
Active Duty Military
Reservist
Veteran (Prior Service)
Veteran (Retired)
Not Reported

Part 2: ACADEMIC INFORMATION

Academic Program Start Date *

Anticipated Graduation Date *

Desired Health Career *

Part 3: FAMILY/BACKGROUND

Please answer Yes or No to the following questions:

You are (or will be) the first generation in your family to attend college. *

Yes
No

You have or currently receive Scholarship or Loan for Disadvantaged Students *

Yes
No

While growing up, you or your family ever used federal or state assistance programs (such as: free or reduced school lunch, subsidized housing, food stamps, Medicaid etc.). *

Yes
No

Grew up in medically underserved area. *

Yes
No

Rural or urban? *

Rural
Urban

Part 4: INTENT

I intend/plan/would like to/ currently work in a primary care setting (e.g. a clinic for Family Medicine, General Internal Medicine, or General Pediatrics). *

I intend/plan/would like to/ currently work with people who are medically underserved, that is people who face economic, cultural or linguistic barriers to healthcare. *

Honors Program for Rural and Urban Underserved Primary Care Medicine

Honors Program Application

Part 1: APPLICANT INFORMATION

Part 2: ACADEMIC INFORMATION

Part 3: FAMILY/BACKGROUND

Part 4: INTENT

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