SHPEP Ambassador Program Application
SHPEP Ambassadors are former participants who volunteer to recruit eligible applicants for the program. The deadline to submit an application is Monday, October 2, 2023, at 11:59 p.m. EASTERN TIME.
Name
*
First Name
Last Name
Current Gender Identity
*
Please Select
Male
Female
Trans male/Trans man
Trans female/Trans woman
Genderqueer/Gender non-conforming
Different Identity
Decline to Answer
How do you self-identify?
*
Please Select
Black or African American
Hispanic, Latino, or of Spanish origin
American Indian or Alaskan Native
Native Hawaiian or Other Pacific Islander
Asian
White
Other (Not Listed)
Decline to Answer
Preferred Email
*
example@example.com
Program Iteration
*
Please Select
MMEP
SMEP
SMDEP
SHPEP
Program Site Attended
*
Please Select
Columbia University
Howard University
Rutgers, The State University of New Jersey
University of Alabama at Birmingham
University of California Los Angeles and Charles R. Drew University
University of Florida
University of Iowa
University of Louisville
University of Nebraska
University of Texas Health Science Center at Houston
University of Washington
Western University of Health Sciences
Other (not listed)
Year Participated
*
Career Pathway
*
Please Select
Dentistry
Medicine
Nursing
Optometry
Pharmacy
Physician Assistant
Physical Therapy
Public Health
Other (Not Listed)
List Campus Involvement
Separate by Comma (e.g., SNMA Maps Chapter, Alpha Phi Alpha Fraternity Inc., Student Government Association, Prehealth Society, etc.)
Year In School
*
Please Select
Freshman
Sophomore
Junior
Senior
Graduate Student (includes health professions programs)
Residency Program
Practicing Health Professional
Institution Type
*
Please Select
Community College
Historically Black College or University (HBCU)
Tribal College or University (TCU)
Predominantly Black Institution (PBI)
Hispanic-Serving Institution (HSI)
Native American-Serving Nontribal Institution (NASNTI)
Alaskan Native- or Native Hawaiian-Serving Institution (ANNHI)
Predominantly White Institution (PWI)
I currently do not attend an institution
Do you plan to take a graduate or professional school entrance exam by August 2024?
*
Yes
No
Which exam do you plan on taking?
*
Please Select
MCAT
DAT
OAT
PA-CAT
GRE
Other (Not Listed)
Do you plan on applying to a health professions program by August 2024?
*
Yes
No
Unsure
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you previously participated as an SHPEP ambassador?
*
Yes
No
Why would you make a great ambassador for SHPEP? What type of outreach activities would you perform to help promote the SHPEP?
*
Maximum: 300 Words
Curriculum Vitae/Resume Upload
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Based on your outreach for SHPEP, what resources would you need to promote the program? What new ideas would you like to implement?
*
Maximum: 300 Words
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