Class of 2026 Prehealth Registration Form

Fill out this form ONLY if you consider yourself to be a prehealth student
'Berg ID
Last Name*
Preferred First Name*
Your Pronouns (e.g., she/her/hers)
Class Year
Please indicate your PRIMARY field of interest in the health professions.*

MedicineDentistryOptometryPodiatryPhysician AssistantNursingPhysical TherapyOccupational TherapyVeterinary MedicinePharmacySpeech-Language-HearingChiropractic Medicine
Please indicate your SECONDARY field of interest in the health professions.

MedicineDentistryOptometryPodiatryPhysician AssistantNursingPhysical TherapyOccupational TherapyVeterinary MedicinePharmacySpeech-Language-HearingChiropractic Medicine
Muhlenberg email*
Cell Phone Number*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent or Guardian # 1 Name
Parent or Guardian #1 Email
Parent or Guardian #2 Name
Parent or Guardian #2 Email
Do any of the following designations apply to you?

Shankweiler ScholarDana ScholarRJ FellowMuhlenberg ScholarNCAA Division III Athlete
ACT Composite
SAT - Mathematics
SAT - Evidence-Based Reading and Writing
SAT - Essay
Have you been accepted into any of the following programs?

UPENN 3+4 BioDentalSUNY Optometry 3+4
Would you be considered "Underrepresented in Medicine (URM)?"*

YesNo
*For our purposes, we are defining this as individuals from racial or ethnic groups underrepresented in medicine and other health professions (including Latinx, Hispanic, Black, African American, Alaska/Hawaii Native, Native American, and Main Land Puerto Rican) or from economically disadvantaged backgrounds or in the first generation of those in their family to attend college.
Should be Empty:

Fill out this form ONLY if you consider yourself to be a prehealth student