University of Tennessee at Martin

Pre-Med Scholars Program

Identifying information

Name: / Major:
UTM ID#: / Academic Advisor:
E-mail: / Class (SO, JR, SR) as of Fall 2017*:
Telephone #: / *Based on number of semesters on campus, not on number of credits.
Extracurricular activities
Honors or Awards while in college
Any situation which mayhave affected or will affect your work during any semester
Any special academic projects, honors courses, etc.
Any other information which might be helpful in completing your evaluation

Faculty reference

Because we may or may not know you well, we would like to ask a UT Martin faculty member about you. Please list the nameand contact information of a faculty member at UTM who know you well and/or with whom you have a good relationship. It is advisable to check with the faculty member before listing him/her to make sure he/she is comfortable providing a brief reference for you.

Name:
Department:
Phone #:
E-mail:
Why do you want to be a physician? Please keep your answer as concise as possible (between 100 and 300 words).
What qualities should a good physician possess and how do you dem7onstrate those qualities?Please keep your answer as concise as possible (between 100 and 300 words).

Release of information

The participating physicians may be consulted on the final selection of participants; however, because they are not UT Martin faculty or staff, they are not allowed access to your private information. In order for them to help us make the best decisions possible, we would like to release your academic information (i.e., your cumulative GPA; your grades in Chemistry 121 and 122 and Biology 130 and 140; and the highest math class you have completed) to them. Please indicate below whether or not you are willing to allow UT Martin to release your academic information to the participating physicians and then sign. I must have an original signature to release your information.

I give permission to release my Pre-Med Scholars application as well as my cumulative GPA; my grades in Chemistry 121 and 122 and Biology 130 and 140; and the highest math class I have completed to the physicians or their designees who are participating in the UT Martin Pre-Med Scholars Program.
I do notgive permission to release my Pre-Med Scholars application as well as my cumulative GPA; my grades in Chemistry 121 and 122 and Biology 130 and 140; and the highest math class I have completed to the physicians or their designees who are participating in the UT Martin Pre-Med Scholars Program.

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