Pre-Dental Mentorship Program Sign Up Form

Personal Details

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

State of Residence

College or University

Major / Field of Study

Current Year in School or Gap Year Status

Intended Dental School Application Cycle

Background & Eligibility

Do you identify as a first- or second-generation immigrant?

Are you currently residing in the United States and hold legal status?

Academic Information

Cumulative GPA (if applicable)

Science GPA (if applicable)

Unofficial Academic Transcript

Have you completed any dental school prerequisite coursework? (Please specify)

Have you taken the DAT or do you plan to take it? If yes, please include the test date and score (if available)

Experiences

Resume or CV

Dental-related experiences (e.g., shadowing, assisting, research, volunteering)

Non-dental extracurricular activities, leadership roles, or community involvement

Goals & Mentorship Needs

How would you describe your current stage in the pre-dental journey?

Which dental schools are you interested in applying to?

Are you considering pursuing a dental specialty in the future? If so, which ones?

What do you hope to gain from participating in this mentorship program?

Are there specific areas in which you are seeking guidance? (e.g., DAT preparation, applications, interviews, school selection)

Commitment & Acknowledgment

Why do you believe you would be a strong fit for this mentorship program?

Are you able to commit to biweekly mentor check-ins and active participation?

Acknowledgment:

I understand that consistent communication is required for participation in this program. I acknowledge that failure to respond to my mentor on three separate occasions may result in removal from the mentorship program.

Signature