M1 Summer Programs Application Applications will be accepted January 29 – March 1, 2024. M1 Summer Programs Application Form APPLICANT INFORMATIONName(Required) First Last Address(Required) Street Address City State / Province / Region ZIP / Postal Code Email(Required) Phone(Required)Gender(Required) Female Male Non-Binary Race American Indian or Alaskan Native: A person having origins in any of the peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Black or African American: A person having origins in any of the black racial groups of Africa. Native Hawaiian or Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, Marshall Islands or other Pacific Islands. White or Caucasian: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Ethnicity Hispanic/LatinX: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Non-Hispanic/LatinX Veteran Status(Required) Individual is not a Veteran Active Duty Military Reservist Veteran (Prior Service) Veteran (Retired) National Guard FAMILY/BACKGROUNDAre you the first generation in your family to attend college?(Required) Yes No Have your previously participated in any UAMS pre-health careers programs? (Example: MASH, CHAMPS, MCAT Prep at ASU, Day in the Life, Pre-Professional Advising)(Required) Yes No If yes, please list the program(s).(Required)Why did you choose medical school?(Required)Are you a member of FMIG?(Required) Yes No Are you a member of RMSLA?(Required) Yes No PRACTICE INTENTHow much do you intend, plan, or want to work in primary care?(Required) Definitely Probably Maybe Probably Not Not At All How much do you intend, plan, or want to work with patients who are medically underserved?(Required) Definitely Probably Maybe Probably Not Not At All How much do you intend, plan, or want to work in a rural area?(Required) Definitely Probably Maybe Probably Not Not At All PROGRAM SELECTIONTell us why you are interested in participating in our programs.(Required)Are you planning to apply to any other summer programs this year (Honors Research, Summer in Surgery, Emergency Medicine Preceptorship, etc.)?(Required) Yes No PRECEPTORSHIP | If you are applying to this program, please list the name of your preferred physician and dates of preceptorship.SERVICE LEARNING PROJECT | If you are applying for this program, in order of preference, please select the project(s) in which you would like to participate. Service Learning Project | First ChoicenoneScreening for Eating Disorders/Using SBIRT for Eating Disorders.Using BH staff to support Health Behavior Change/ working with Interdisciplinary teamsMedication Assisted TreatmentAdvanced Care Plans - why this is so important with patient careCollaborative Care Model - using the Psychiatric Consultation model in Primary CareQuick Anxiety reduction skills for physician useStrategies to support wellness/well-being for physiciansScreening for Autism, development delaysUsing Motivational Interviewing skills to support Smoking CessationScreening for substance use in Primary CareService Learning Project | Second ChoicenoneScreening for Eating Disorders/Using SBIRT for Eating DisordersUsing BH staff to support Health Behavior Change/ working with Interdisciplinary teamsMedication Assisted TreatmentAdvanced Care Plans - why this is so important with patient careCollaborative Care Model - using the Psychiatric Consultation model in Primary CareQuick Anxiety reduction skills for physician useStrategies to support wellness/well-being for physiciansScreening for Autism, development delaysUsing Motivational Interviewing skills to support Smoking CessationScreening for substance use in Primary CareService Learning Project | Third ChoicenoneScreening for Eating Disorders/Using SBIRT for Eating DisordersUsing BH staff to support Health Behavior Change/ working with Interdisciplinary teamsMedication Assisted TreatmentAdvanced Care Plans - why this is so important with patient careCollaborative Care Model - using the Psychiatric Consultation model in Primary CareQuick Anxiety reduction skills for physician useStrategies to support wellness/well-being for physiciansScreening for Autism, development delaysUsing Motivational Interviewing skills to support Smoking CessationScreening for substance use in Primary CareMASH ASSISTANTSHIP | If you are applying to this program, in order of preference, please select the location of the camp(s) in which you would like to assist. MASH Camp Location | First ChoicenoneArkansas Methodist Medical CenterArkansas Northeastern College - BlythevilleAshley County Medical CenterBaptist Health - ArkadelphiaBaptist Health - Fort SmithBaptist Health - Hot Spring CountyBatesvilleBradley County Medical CenterCHI St. Vincent - Hot SpringsConway Regional Medical CenterCrittenden CountyDelta Memorial HospitalDeWitt HospitalDrew Memorial Health SystemEl DoradoFayettevilleForrest CityHarrisonHelena/West HelenaMercy Hospital - Fort SmithMercy Medical Center - RogersPine BluffTexarkanaMASH Camp Location | Third ChoicenoneArkansas Methodist Medical CenterArkansas Northeastern College - BlythevilleAshley County Medical CenterBaptist Health - ArkadelphiaBaptist Health - Fort SmithBaptist Health - Hot Spring CountyBatesvilleBradley County Medical CenterCHI St. Vincent - Hot SpringsConway Regional Medical CenterCrittenden CountyDelta Memorial HospitalDeWitt HospitalDrew Memorial Health SystemEl DoradoFayettevilleForrest CityHarrisonHelena/West HelenaMercy Hospital - Fort SmithMercy Medical Center - RogersPine BluffTexarkanaMASH Camp Location | Second ChoicenoneArkansas Methodist Medical CenterArkansas Northeastern College - BlythevilleAshley County Medical CenterBaptist Health - ArkadelphiaBaptist Health - Fort SmithBaptist Health - Hot Spring CountyBatesvilleBradley County Medical CenterCHI St. Vincent - Hot SpringsConway Regional Medical CenterCrittenden CountyDelta Memorial HospitalDeWitt HospitalDrew Memorial Health SystemEl DoradoFayettevilleForrest CityHarrisonHelena/West HelenaMercy Hospital - Fort SmithMercy Medical Center - RogersPine BluffTexarkanaPlease select the weeks in which you are available to serve as a MASH Camp Assistant. June 3 - 7, 2024 June 10 - 14, 2024 June 17 - 21, 2024 June 24 - 28, 2024 July 1 - 5, 2024 July 8 - 12, 2024 July 15 - 19, 2024 July 22 - 26, 2024
