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Medical H.E.L.P. Application

Name (Last, First) *

Email *

Phone *

Current Address *

Apt, suite, etc.

Country

City

State

Zip code

Permanent Address *

Apt, suite, etc.

Country

City

State

Zip code

Date of Birth *

Drivers License # and Issuing State *

(Needed for MU computer accounts)

Name *

Phone *

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 *

Write a synopsis of your difficulties. Detailed histories give us a better understanding of your learner profile. *

What program are you interested in? *

4-Week Comprehensive Program

2-Week Intensive Program

Individual one-on-one Training

If you chose one-on-one training, what goals are you hoping to meet through Medical H.E.L.P. training? *

Referral

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

Name of referral *

Profession *

Email *

Phone *