Marshall University H.E.L.P. Program

If you experience any issues with this form not submitting, please contact Ryan Orwig at (304)696-6315 or Orwig1@marshall.edu

Section I: General Information
First Name:
Middle Name:
Last Name:
Social Security Number:
Birth Date:
Phone Number:
E-Mail:
Drivers License Number: If no license put N/A
Drivers License Issuing State:

Current Address

Street Address:

City:

State:

Zip:

Permanent Address (Leave blank if same as current address)

Street Address:

City:

State:

Zip:

Emergency Contact Name:
Emergency Contact Number:
Section II: MCAT
How many times have you taken the MCAT?
Provide dates taken and scores (VR, BS, PS, Writing):
Section III: Medical School History
Where do you (or did you) attend medical school?
List medical schools you have been enrolled in in the past:
List the reasons for leaving (if applicable):
If you are still attending, what is your current status? (Be specific):
List your difficult courses, noting those you have failed and/or repeated:
Note:Leave Dates as 00/00/0000 if you havn't taken the USMLE
USMLE Step 1 Date:
USMLE Step 1 Scores:
USMLE Step 2 Date:
USMLE Step 2 Scores:
USMLE Step 3 Date:
USMLE Step 3 Scores:
Relevant board scores beyond step exams:
If your program uses different exams, list types of exam, date of exam, and scores. (EX: complex, podiatry boards, etc.):
If applicable, what is (or was) your field of residency:
If applicable, where do you (or did you) do your residency:
Section IV: Academic and Accommodations History
Please write a synopsis of your difficulties -- Please note that detailed histories help us construct an understanding of your profile:
Problems with standardized exams:
Problems with pacing during exams:
Accommodations you have been granted in the past:
Accommodations you have applied for & been denied:
Accommodations you think you require:
Section V: Diagnostic Testing Information
Person / Faculty conducting the evaluation(s):
Dates of evaluation(s):
Location(s) of the evaluation(s):
Conclusions:
Section VI: Additional Information
Spouse's Name:
Alternate Phone Number:
Father's Name:
Mother's Name:
Parent's Address
Street Address:
City:
State:
Zip:
How did you find out about the Medical H.E.L.P. Program?
If you used the internet, what search engine did you use?
If you used the internet, what search terms did you use?

*Contact Diana Porter, HELP Program Business Manager, to arrange $500 down payment: 304.696.5220 or porterd@marshall.edu

*Any other questions, contact Ryan Orwig, Medical HELP Coordinator, at 304.696.6315 or orwig1@marshall.edu

**All fields written in gray are optional


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