2024-2025 Big Doc Form

Student Affairs

200 University Parkway, Suite 317

Yakima WA 98901

Phone: 509-249-7724

Fax: 509-249-7909
Big Doc Form
* You are not required to answer all questions, if you feel uncomfortable answering any questions feel free to leave it blank as this is just a way to match people up with students who are in similar situations.
Full name:*

First NameMiddle NameLast Name
E-mail*
Program*
Gender

MaleFemaleOther
Age:
Hometown and state:
Undergraduate school:
Undergraduate degree/major:
In a relationship?

YesNo
If in a relationship do they live in Yakima?

YesNo
Married:

YesNo
Children:

YesNo
Do you identify with the LGBTQ+ community?
If yes, how do you identify?
Would you be willing to be a "Big Doc" ally for LGBTQ+ students? This means supporting their equal rights movement.
What are your pronouns?

She/herHe/himThey/themPrefer not to answerOther

What groups do you identify with that you want your counterpart to mirror (or at least be educated about)? Please note which one is the most important on a scale of 1-5 (1 being the most important and 5 being the least important) to you for matching purposes, and we will try our best to pair you with a corresponding student doctor.

	1 (most important)	2	3	4	5 (least important)
Race
Ethnicity
Religion
Political Views
Other
None of the Above/Prefer not to answer

Race (check as many as applies)

Prefer not to answerAmerican Indian or Alaskan NativeAsianAfrican AmericanPacific IslanderCaucasianOther
Ethnicity
(Include multiple ethnicities, if applicable)
Religion

Prefer not to answerCatholicChristianChurch of Jesus Christ of Latter-day SaintsJewishHinduBuddhistMuslimWiccanAtheistAgnosticOther
Political Views

DemocratRepublicanOther
Other identities not listed:
Hobbies:
What Medical Specialties are you interested in?
Would you be willing to work with more than one little doc?

YesNo
If you know someone who was accepted and would like to be their Big Doc write their name(s) here so we can be sure and pair you up:
Is there anything else you think is important for us to know when matching you up with a little doc?
Should be Empty: