Cost  of the program is $4,500 for out of state participants

 and 3,500 for in-state.

 To register for Medical H.E.L.P., a non-refundable deposit of $500 is required.    It will be deducted from the total amount due, at a later date.

Please check which method you prefer:

My Check for $500 will be mailed immediately.

    Please mail to:

Medical H.E.L.P. Program                                                                                                                              520-18th street ,Huntington WV 25755

I will give the Business Manager my credit card number by calling (304)696-5220.

My credit card is Visa Master Card  Expiration Date : Month Year

 The name that appears on the credit card is

I wish to participate in the Medical H.E.L.P. Program on this date

 4 SECTIONS (SELECT THE ONE  THAT IS CONVENIENT FOR YOU.)

Section A-General Information--All students must complete.

Last Name     

Mother's Maiden Name     

First Name    

Middle Name

Social Security Number  

Drivers License Number  

Current Street Address

Current City Current State

Current Zip

Permanent Street Address

Permanent City Permanent State

Permanent Zip 

Date of Birth     (MM/DD/YYYY)

Phone Email

Employer

Section B-Education History

1.Have you taken the MCAT? Yes No

If so, please list the scores from previous attempts and the respective dates of administration.

2.Have you ever applied for medical school in the past and not to been accepted?

Yes No

If so, where did you apply and why were you rejected?

3. In what school are you currently enrolled?

4.List any medical schools which you have been enrolled in the past.

Please list the reasons for leaving.

5.Where do you (or did you) attend medical school?

If you are still attending, what is your current status?

6.List courses with which you had particular difficulty. Please note if any of them had to be repeated.

7.Have you ever taken the USMLE step1? Yes No

 USMLE step 1-date-1st time      (MM/DD/YYYY)

 USMLE step 1-score-1st time

 USMLE  step 1-pass-1st time    

8. Have you ever taken the USMLE 2? Yes No

 USMLE step 2-date-1st time      (MM/DD/YYYY)

 USMLE step 2-score-1st time

 USMLE  step 2-pass-1st time    

9.What is, or was your field of residency

   Where do you, or did you, do your residency

10.Have you taken the USMLE step 3? Yes No

 USMLE step 3-date-1st time      (MM/DD/YYYY)

 USMLE step 3-score-1st time

 USMLE  step 3-pass-1st time    

11.Have you taken a Specialty Board Exam (SBE)? Yes No

 SBE date-1st time     (MM/DD/YYYY)

 SBE scorce-1st time

 SBE pass-1st time    

Section C-History of Problems-All students must complete.

1. Please write a Synopsis of the difficulty you have experienced in your academic career. Note at which points, if any, you sought diagnosis testing and the diagnosis made at that time. The next section will request more information on these evaluations.

2. Do you characterize yourself as having a history of problems with standardized exams?

Yes No

3. Do you have a problem with pacing during exams?

Yes No

4. Check any accommodations you have received in the past.

Time extension                                   Reader scribe

Separate room                                    Adjustment in breaks     Explain

Other-Explain

5.Check which accommodations you feel you currently need in order to be successful.

Time extension                                    Reader scribe

Separate room                                     Adjustment in breaks    Explain

Other-Explain

Section D-Diagnostic Testing-All students must complete.

 Date of Evaluation

 Person/Facility Conducting the Evaluation

 Location of the Evaluation

 Conclusions :

Diagnostic Checklist (Check all that apply.)

Dyslexia                                    ADHD Combined

Dystrophia                                Reading

Dyscalculia                               Written language

Nonverbal LD                            OHD Hyperactivity

ADHD non-attentive                Other

Section E-Additional Contact information -All students must complete.

In case of emergency, we need contact information for you.

Spouse's Name   Alternative Phone Number

Father's Name Mother's Name

Parents' Address

 Street Address

 City  

 State   Zip Code

Section F-All students must complete.

Do you want to tell us how you found out about our program?

Yes No

Referred by former student of the Medical H.E.L.P.Program.

     Name

Referred by school or hospital administrator.

     Name     Position

A learning disability specialist, ADHD, or diagnostic specialist.

     Name      Position

AD in the New Physician

Internet Website

     Which search engine did you use and what did you search on?

Google AdWords (Advertisement on web content pages)

Other

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We will observe this request whenever possible. Thank you!