FP3 Student Application Form
APPLICANT INFORMATION
Full Name:
Preferred Name:
Date of Birth:
-
Month
-
Day
Year
Date
Age:
Gender:
Male
Female
Non-binary
Prefer not to say
Race/Ethnicity;
I am a U.S. citizen or legal resident:
Yes
No
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
ACADEMIC INFORMATION
Current School Name:
County of the School: Henry, Clayton or Fayette
Grade Level (for upcoming school year): 4th 5th 6th 7th 8th 9th 10th 11th 12th
Cumulative GPA (if in Middle or High School):
Favorite Subjects:
Career Interests::
MENTORSHIP PROGRAM INTEREST
Why are you interested in being a medical doctor? (250 words)
Back
Next
What do you hope to gain from having a mentor?
Have you participated in any science, medical, STEM, or health-related programs before?
Yes
No
If yes, name of program:
AVAILABILITY & COMMITMENT
Are you available to attend monthly sessions (in-person on Saturday mornings once a month)?
Yes
No
Do you have access to reliable internet and a device for virtual meetings?
Yes
No
Are you willing to commit to the full program year?
Yes
No
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name:
Relationship to Student:
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Emergency Contact Name & Phone:
SIGNATURES
I understand that submitting this application does not guarantee acceptance into the program. I commit to participating fully if selected. I may be removed from the program if I am not attending consistently.
Student Signature:
Date:
-
Month
-
Day
Year
Date
Parent/Guardian Signature:
Date:
-
Month
-
Day
Year
Date
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