Apply Now

Medical HELP Application

Name

First Last

Phone

Current Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Permanent Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Which Medical HELP course are you interested in?

How many times have you taken the MCAT?

Provide scores and approximate date(s).

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

What other medical schools have you attended?

List reasons for leaving

If you\'re still attending medical school, what is your current status (be as specific as possible)

List your most difficult courses and note those you have failed or have had a marginal pass

Name and agency of person conducting evaluation

Date of Evaluation

Conclusions or notable findings

How did you find out about the Medical H.E.L.P. Program?

Name of referral

First Last

Profession

Phone