Future Superhero of Medicine Funding Request
Supporting programs that empower and encourage Black students and students from other communities that are under-represented in medicine to pursue careers in health and medicine
Applicant Information
I affirm I am a Black student or a student from another community that is under-represented in medicine student pursuing a career in health and medicine.
Yes
No
I am enrolled at, or intend to apply to, medical school in Wisconsin?
Yes
No
Unsure
Name of individual completing this application
*
First Name
Last Name
Preferred name
How would you like to be addressed in correspondence?
Pronouns
Email
*
Confirmation Email
A copy of your responses will be sent to this address.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone number
*
-
Area Code
Phone Number
Please provide the name of your current school? (If applicable.)
What is your expected year of graduation? (If applicable.)
Please briefly share what your future career plans are specifically related to health and medical fields and why you are pursuing this path:
What have been some of the barriers in your way to pursuing a career in medicine and what things do you wish were in place to better support you:
What is your connection to the State of Wisconsin or to practicing in Wisconsin?
Please indicate which 90 day UWORLD Qbank Subscription you are applying for access to:
MCAT
Step 1
Step 2 CK
Please verify that you are human
*
Submit
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