Surveypoint

Q1

First Name

Name*

Q2

Last Name

Name*

Q3

Gender*

Male

Female

Q4

Month

Birth Date*

Q5

Day

Birth Date*

Q6

Year

Birth Date*

Q7

Race*

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Q8

Ethnicity*

Hispanic

Non-Hispanic

Q9

Mobile Number*

Q10

Email*

Q11

Street Address

Current Address*

Q12

Street Address Line 2

Current Address*

Q13

City

Current Address*

Q14

State / Province

Current Address*

Q15

Postal / Zip Code

Current Address*

Q16

How did you hear about this program?*

Q17

University Name*

Q18

Graduation Date (estimate)*

Q19

Interested Major*

Q20

What stage of the medical school application process are you in?*

Reapplying next cycle or in the future

Applying next cycle (for the first time)

Q21

What do you hope to gain from the Medical Student for a Day program? *

Q22

If you had enormous wealth, how would you allocate your charitable donations?*

Q23

If you could choose your nickname, what would it be and why?*

Q24

Personal Statement*

Q25

Writing Supplemental Prompts: Choose one to complete

Describe an experience where you were unsuccessful in achieving your goal. What lessons did you learn from that experience?

What are you passionate about?

What movie, poem, musical composition, song, or novel has most influenced your life and the way that you view the world?

What is the most fun you have had recently?

Q26

Optional Supplement

Q27

Current GPA

Q28

Have you taken the MCAT?

Q29

If yes, what was your score?

Q30

Is there any other information that you would like to share with us?

Q31

By my signature, I certify that the information I have provided is accurate and complete. If accepted, I understand that I am expected to attend the program. I acknowledge that it is my responsibility to notify the program if I can no longer attend.*

Msfad -Form Fill

First Name

Last Name

Gender*

Month

Day

Year

Race*

Ethnicity*

Mobile Number*

Email*

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

How did you hear about this program?*

University Name*

Graduation Date (estimate)*

Interested Major*

What stage of the medical school application process are you in?*

What do you hope to gain from the Medical Student for a Day program? *

If you had enormous wealth, how would you allocate your charitable donations?*

If you could choose your nickname, what would it be and why?*

Personal Statement*

Writing Supplemental Prompts: Choose one to complete

Optional Supplement

Current GPA

Have you taken the MCAT?

If yes, what was your score?

Is there any other information that you would like to share with us?

By my signature, I certify that the information I have provided is accurate and complete. If accepted, I understand that I am expected to attend the program. I acknowledge that it is my responsibility to notify the program if I can no longer attend.*