Pre-Health Student Registration
2026-2027 Academic Year
Section 1: Personal Information
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
Preferred Name (if applicable)
*
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
Student ID Number
*
Section 2: Contact Information
Email Address
*
example@example.com
Mobile Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Section 3: Academic Information
Current Education Status
*
Undergraduate Student
Post-Baccalaureate Student
Graduate Student
Other (Please Specify)
Institution Name
*
Major
*
Minor (if applicable)
*
Put N/A if not applicable.
Current GPA
*
Academic Classification
*
Freshman
Sophomore
Junior
Senior
Graduate Student
Section 4: Healthcare Career Interest
Which healthcare profession(s) are you interested in pursuing? (Select all that apply)
*
Medicine (MD/DO)
Physical Therapy (DPT)
Occupational Therapy (OTD/MSOT)
Physician Assistant (PA)
Nursing
Dentistry
Pharmacy
Optometry
Podiatry
Veterinary Medicine
Public Health
Health Administration
Other (Please Specify)
Primary Career Goal
*
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Section 5: Experience and Exposure
Have you completed any of the following?
*
Rows
YES
NO
Job Shadowing
Clinical Volunteering
Paid Healthcare Experience
Research Experience
Leadership Activities
Community Service
Total Clinical Hours Completed
*
Total Volunteer Hours Completed
*
Section 6: Program Participation
How did you hear about this program?
*
Faculty Advisor
Academic Advisor
Friend/Student
Social Media
Website
Email Announcement
Other (Please Specify)
What are you hoping to gain from this program? (Select all that apply)
*
Career Exploration
Advising/Mentoring
Application Preparation
Interview Preparation
Professional Networking
Clinical Exposure
Research Opportunities
Leadership Development
Advising Questions
1. Why are you interested in a healthcare career?
*
2. What are your greatest strengths as a future healthcare professional?
*
3. What concerns or challenges do you anticipate in your pre-health journey?
*
4. Would you like to be paired with a mentor?
*
Yes
No
5. Are you interested in:
*
Research Opportunities
Service Learning
Clinical Placements
Scholarship Information
Application Workshops
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Section 7: Emergency Contact
Emergency Contact Name
*
Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Email Address
*
example@example.com
Section 8: Consent and Acknowledgment
Electronic Signature
*
Please verify that you are human
*
Submit
Submit
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