The Honors Program in 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

Race *

American Indian/ Alaskan Native
Asian
Black or African American
Native Hawaiian/ Pacific Islander
White/Caucasian
More than One Race
Other
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 the first generation in your family to attend college. *

Yes
No

You currently receive a scholarship or loan for disadvantaged students. *

Yes
No

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

Yes
No

You grew up in a medically underserved area. *

Yes
No

I grew up in a rural/urban environment. *

Rural
Urban

Part 4: INTENT

I intend to work in a priamry care setting (i.e., Family Medicine, General Internal Medicine, or General Pediatrics). *

I intend to work with people who are medically underserved (i.e., people who face economic, cultural, or linguistic barriers to adequate healthcare). *

I intend to work in a rural area. *

What are the things which most interest and inspire you about our Honors Program? Why do you think this Honors Program will be valuable to your education and future career? Please be as brief or descriptive as you like.

The Honors Program in 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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