M1 Summer Programs Application Applications will be accepted January 30 – February 13, 2023. 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(Required) 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(Required) 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 ChoicenoneBrief Interventions for Treatment of Insomnia and Other Sleep DisordersScreening and Treatment for Anxiety Disorders in Primary Care ClinicsBehavioral Health Interventions to Support Management of Chronic PainImpact of Childhood Trauma on Adult Health OutcomesWhy MAT Makes Sense in Primary Care SettingsImportance of Screening for Substance Use Disorders and Early InterventionSupporting Health Behavior Change in Primary Care Patients Using BH TechniquesBest Practices in Care Teams or Complex Care Team ModelsAdvanced Care Planning - Why This is Important in Patient CarePsychiatric Consultation Models in Primary Care SettingsService Learning Project | Second ChoicenoneBrief Interventions for Treatment of Insomnia and Other Sleep DisordersScreening and Treatment for Anxiety Disorders in Primary Care ClinicsBehavioral Health Interventions to Support Management of Chronic PainImpact of Childhood Trauma on Adult Health OutcomesWhy MAT Makes Sense in Primary Care SettingsImportance of Screening for Substance Use Disorders and Early InterventionSupporting Health Behavior Change in Primary Care Patients Using BH TechniquesBest Practices in Care Teams or Complex Care Team ModelsAdvanced Care Planning - Why This is Important in Patient CarePsychiatric Consultation Models in Primary Care SettingsService Learning Project | Third ChoicenoneBrief Interventions for Treatment of Insomnia and Other Sleep DisordersScreening and Treatment for Anxiety Disorders in Primary Care ClinicsBehavioral Health Interventions to Support Management of Chronic PainImpact of Childhood Trauma on Adult Health OutcomesWhy MAT Makes Sense in Primary Care SettingsImportance of Screening for Substance Use Disorders and Early InterventionSupporting Health Behavior Change in Primary Care Patients Using BH TechniquesBest Practices in Care Teams or Complex Care Team ModelsAdvanced Care Planning - Why This is Important in Patient CarePsychiatric Consultation Models in Primary Care SettingsMASH 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 ChoicenoneArkadelphiaBatesvilleBlythevilleCamdenClintonCrossettDeQueenEl DoradoFayettevilleFordyceForrest CityFort SmithHarrisonHeber SpringsHelenaJonesboroLake VillageMagnoliaMenaMonticelloMountain HomeMountain ViewNashvilleParagouldPine BluffPocahontasRogersRussellvilleTexarkanaVan BurenWarrenWest MemphisMASH Camp Location | Second ChoicenoneArkadelphiaBatesvilleBlythevilleCamdenClintonCrossettDeQueenEl DoradoFayettevilleFordyceForrest CityFort SmithHarrisonHeber SpringsHelenaJonesboroLake VillageMagnoliaMenaMonticelloMountain HomeMountain ViewNashvilleParagouldPine BluffPocahontasRogersRussellvilleTexarkanaVan BurenWarrenWest MemphisMASH Camp Location | Third ChoicenoneArkadelphiaBatesvilleBlythevilleCamdenClintonCrossettDeQueenEl DoradoFayettevilleFordyceForrest CityFort SmithHarrisonHeber SpringsHelenaJonesboroLake VillageMagnoliaMenaMonticelloMountain HomeMountain ViewNashvilleParagouldPine BluffPocahontasRogersRussellvilleTexarkanaVan BurenWarrenWest MemphisPlease select the weeks in which you are available to serve as a MASH Camp Assistant. June 5 - 9, 2023 June 12 - 16, 2023 June 19 - 23, 2023 June 26 - 30, 2023 July 3 - 7, 2023 July 10 - 14, 2023 July 17 - 21, 2023 July 24 - 28, 2023
