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Marshall University Medical H.E.L.P. Program

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Medical H.E.L.P. Application

General Information

Name (Last, First) *
Email *
Phone *
Current Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Permanent Address *
Permanent Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Date of Birth *
Drivers License # and Issuing State (Needed for MU computer accounts)

Emergency Contact

Name *
Phone *

MCAT

How many times have you taken the MCAT?
Provide scores and approximate date(s)

Medical School

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

Diagnostic Testing

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

Verification

Please enter any two digitsExample: 12
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