Summer Opportunities Application

APPLICANT INFORMATION

Name *

First Last

Address *

Street Address City State / Province / Region ZIP / Postal Code

Email *

Phone *

Race/Ethnicity *

American Indian/Alaskan Native
Asian
Black or African American
Native Hawaiian/Pacific Islander
White/Caucasian

FAMILY/BACKGROUND

Are/Were you the first generation in your family to attend college? *

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) *

Yes
No

If yes, please list the program(s). *

Why did you choose medical school? *

Are you a member of FMIG? *

Yes
No

Are you a member of RMSLA? *

Yes
No

PRACTICE INTENT

How much do you intend, plan or want to work in primary care? *

How much do you intend, plan or want to work with patients who are medically underserved? *

How much do you intend, plan or want to work in a rural area? *

PROJECT SELECTION

Tell us why you are interested in participating in our programs. *

In order of preference, please list the service learning project(s) in which you would like to participate. A list of project topics is available in the summer opportunities handbook. *

Are you planning to apply to any other summer programs this year (Honors Research, Summer in Surgery, Emergency Medicine Preceptorship, etc.)? *

Yes
No

If you are applying to other summer programs, please list them here. *

Summer Opportunities Application

Summer Opportunites Application Form

APPLICANT INFORMATION

FAMILY/BACKGROUND

PRACTICE INTENT

PROJECT SELECTION

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