Class of 2029 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
IF YOU ARE STILL DECIDING, 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
Do any of the following designations apply to you?

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

UPENN 3+4 BioDentalSUNY Optometry 3+4
The following questions are optional, but can help the prehealth advisor ensure you receive important and relevant information pertaining to your unique identity.
Do you identify with any of the following: Latinx, Hispanic, Black, African-American, Alaska/Hawaii Native, Native American, MainLand Puerto Rican

YesNo
Are you a first-generation college student?

YesNo
Did you receive a Pell Grant as part of your financial aid package?

YesNo
If you would like general information about the prehealth program at Muhlenberg to be shared with a parent or other family members, please provide their name and email address.
Parent Name

First NameLast Name
Parent Email Address
example@example.com
Should be Empty:

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