Apply – Medical Enhancement Programs

Which program are you applying for? (program dates)*

Other program dates of interest? (if applicable)

Exclusive ID#:

(Are you applying for a program reserved by an organization/group? If so, enter the organization's Exclusive ID# here.)

Name:*

First: Last:

Exactly as shown on your passport*

Preferred Pronoun:

Preferred Name/Nickname:

Email 1:*

Email 2:

Home Phone:*

Cell Phone:*

Current Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth:*

Birthplace:*

Gender Identity:*

Legal Residence State:*

State / Province / Region

Are you a U.S. Citizen or have permanent residence in the U.S.?*

How did you hear about us?*

Have you previously attended any other medical mission trips?*

Yes
No

Affiliation to any student organization or group?

PARENT/GUARDIAN INFORMATION

Name:*

First: Last:

Relation:*

Phone:*

Email:*

Occupation:

OTHER INFORMATION

What languages do you speak?

Are you a first-generation college student?

List any awards, honors, certifications, medical experiences, etc.:

HIGH SCHOOL EDUCATION

High School Name:

Graduation Year:

Address:

UNDERGRADUATE EDUCATION

Name of Institution:*

City: State: Country:

Dates of Attendance:*

Major:

Minor:

Degree Pursued/Earned:

Expected Graduation Year:*

Overall GPA:

Career Plans:*

[Undecided, Medicine, Pharmacy, Physician Assistant, Nursing, Medical Research, etc.]

ESSAY

Please write an essay below.

Why are you interested in applying to a MedX Program?*

IMPORTANT:

Please upload transcripts and resume below.

Resume

Max. file size: 50 MB.

Unofficial Transcript

Max. file size: 50 MB.

File

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File

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File

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File

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File

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File

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Comments:

Program Application

Student Application

PARENT/GUARDIAN INFORMATION

OTHER INFORMATION

HIGH SCHOOL EDUCATION

UNDERGRADUATE EDUCATION

ESSAY

IMPORTANT: