Mentoring in Medicine, Inc

Mentoring In Medicine, Inc.

Medical Pathway Program (MPP) 2012-2013

Application Form

DEADLINE TO APPLY Friday, November 23, 2012

Class Runs from Saturday, December 1, 2012-Saturday, April 20, 2013

All information on the application will remain confidential. Please complete ALL sections that apply.

Section 1A: Personal Information (please print clearly)

Full Name: ______Date Of Birth: ______

Mailing Address: ______E-Mail Address: ______

Home Phone: ______Cell Phone: ______Best Way to Contact: ______

Are you a US citizen? ___Yes ___No

Section 1B: Emergency Contact

Full Name: ______Date Of Birth: ______

Mailing Address: ______E-Mail Address: ______

Home Phone: ______Cell Phone: ______Best Way to Contact: ______

Section 2: Academic Profile

Undergraduate College: ______Major: ______Minor: ______

Date of Graduation: ____/____/____ Degree: ______Overall GPA: ______Science GPA: ______

Other University/ College: ______Major: ______Minor: ______

Date of Graduation: ____/____/____ Degree: ______Overall GPA: ______Science GPA: ______

Extracurricular Activities: ______

Summer Activities: ______

______

Have you completed the following prerequisites (Put a Check by “Yes” or “No”)? If “yes”, please indicate “X” how long ago you took each:

Taken Course? / Currently? / 1 to 2 years? / 2 to 3 years? / 4 or >?
BIOLOGY / Yes / No
PHYSICS / Yes / No
GENERAL CHEMISTRY / Yes / No
ORGANIC CHEMISTRY / Yes / No

Section 3: Mentoring in Medicine Background

1. How did you hear about the program? ______

2. Who referred you? ______

3. Have you participated in MIM Programs? ____ Yes _____ No

4. If “Yes”, which ones? ______

Section 4: History/ Record (Required)

Have you ever been charged or convicted of a misdemeanor, felony or crime? _____Yes ____No

Section 5: MCAT History and Preparation

1. What is your current target MCAT Score? PS: ______BS: ______BS: ______WS: ______

2. Have you previously/ currently enrolled in a commercial MCAT Prep course? ____ Yes _____ No

a. If “Yes”, please indicate when you took the course: From ____/____/______To ____/____/______

b. Please check which course name:

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____ Princeton Review

____ Kaplan

____Exam Krackers

____ School Sponsored Course

____ Private Tutor

____ Other: (Indicate) ______

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3. Have you taken an Office AAMC MCAT before?

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___No

___Yes, once

___Yes, twice

___Yes, 3 times or more

(Please indicate number of times :______)

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(*If you answered “No” in Question #3, please ignore questions a, b, and c.)

a) If “Yes”, please indicate separate scores PS/VR/BS/WS and date (Add more rows if needed):

· 1st Test Date: ______PS: ______BS: ______BS: ______WS: ______

· 2nd Test Date: ______PS: ______BS: ______BS: ______WS: ______

· 3rd Test Date: ______PS: ______BS: ______BS: ______WS: ______

· 4th Test Date: ______PS: ______BS: ______BS: ______WS: ______

b) From your AAMC exams listed above, what preparations have you used and rate the effectiveness and level of quality during your previous study plan from a scale of 1 (Poor) to 5 (Excellent)?

Poor Fair Good Very Good Excellent

1. Prep:______1 2 3 4 5

2. Prep:______1 2 3 4 5

3. Prep:______1 2 3 4 5

4. Prep:______1 2 3 4 5

c) Indicate why you feel unsatisfied with (each of) your current scores and rate the level of difficulty you felt during each of the test(s) from a scale from 1 (Very Difficult) to 5 (Very Easy)?

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Reason: ______

Very Difficult Difficult Neutral Easy Very Easy

1 2 3 4 5

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4. Please answer the following questions, regarding your MCAT Study Plan:

a) Indicate tentative date you plan to take MCAT: ___/____/____

b) What date do you plan to start to study for the MCAT? ___/____/____

c) Number of hours per week dedicate to studying: ______Number of hours per day: ______

Mon: ______Tues: ______Wed: ______Thurs: ______Fri: ______Sat:______Sun: ______= (total) ______

d) Discuss concerns that may occur to prevent effective studying: ______

5. Briefly explain what you think we can assist you with to achieving your best on the MCAT: ______

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Section 6 - Health Professional School Application History

1. Have you applied to medical school before? ___No ___Yes, once ___Yes, twice ___Yes, 3 or more

2. Indicate the year(s)/ No. of school(s): ______

Section 7 – MCAT Exam Anticipation Date

1. Are you currently registered for the Official AAMC MCAT Exam during 2013? ____ Yes _____ No

§ If “Yes”, what date and time? On ___/____/____ at ___: ____ AM/PM

§ If “No”, mark when do you anticipate registering the exam?

(_) I will register on: ___/____/____

(_) I will register when registration is available to register.

(_) I will register as soon as possible.

(_) I will register when I have funds available.

Section 8: Personal Statement

Please complete the following essay in no more than one page typed, single space, 12 pt., Times New Roman Font. PLEASE ANSWER THE FOLLOWING QUESTIONS TO THE BEST OF YOUR ABILITY.

Why do you want to be a physician? What challenges have you encountered?

Section 9: Two (2) Recommendation References (Note: References may be contacted.)

1. Name: ______Relation to Applicant: ______
Mailing Address: ______
Email Address: ______
Phone (Office): ______Phone (Cell): ______

2. Name: ______Relation to Applicant: ______
Mailing Address: ______
Email Address: ______
Phone (Office): ______Phone (Cell): ______

3. Name: ______Relation to Applicant: ______
Mailing Address: ______
Email Address: ______
Phone (Office): ______Phone (Cell): ______

Section 10: Payment Information

FEES *Scholarships are available.*

$497-In-class fee for students in the NY metropolitan area and the “live” webcast fee

FREE application fee.

(1) Check to Mentoring in Medicine, Inc., 211 East Main Street, # 294, New Rochelle, NY 10801

(2) Credit Card Payment via http://medicalmentor.org/?page_id=556

PAYMENT OPTIONS**

** Participation in this program does NOT guarantee admission to medical school.

____I have included the program cost in full.

____I would like to pay via the following payment plan. **Includes $3 processing fee.**

In-Class “Live” Webcast

December 15, 2012 $100 $100

January 15, 2013 ` $100 $100

February 15, 2013 $100 $100

March 15, 2013 $100 $100

April 15, 2013 $100 $100

____ I would like to apply for a scholarship for the course.

Please write a one page essay detailing your reasons for requesting financial assistance. Scholarships are available.

You will be notified of your scholarship status by Monday, November 26, 2012.

Section 11: Press Release Forms

In exchange for consideration received, I hereby give permission to Mentoring in Medicine to use my name and photographic likeness in all forms and media advertising, trade and any other lawful purposes. If under 18, I am the parent or legal guardian of the individual named above. I have read this release and approve of its terms.

Print Name: ______

Signature: ______Date: ______

Section 12: Picture (Please send a current picture with your application.)

E-mail your completed application to with MPP Application in the subject line. NOTE: Incomplete applications or applications without the deposit will NOT be considered.

CHECKLIST:

⁯ Complete all information requested in Sections 1-12.

⁯ Personal Statement

⁯ Financial Assistance Request (if requesting a partial or full scholarship)

⁯ Three (3) Recommendation Reference Contacts (Letters are not required.)

⁯ Press Release Electronic Signature

⁯ A Current Profile Photo

Application due date is by midnight. You will be notified by e-mail of your acceptance.

o 2012-2013 Session Deadline to Apply is Friday, November 23, 2012

Thank you for your application!

Mentoring in Medicine is a nonprofit organization dedicated to mentoring, academic enrichment and leadership development for socioeconomically disadvantaged students and students underrepresented in medicine (African-American, Hispanic, and Native American). Programs have been featured in The New York Times, JET, Essence and the NY Daily News. All are invited to apply.

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