Southern KY AHEC Future Docs Program Application 2024

Personal Information

• * First Name:
• * Last Name:
• * Email Address:
• * Confirm Email Address:
• * Address 1:
• * City:
• * State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• * ZIP Code:
• * Phone:
• * Cell Phone:

• Gender

  • Male
  • Female
• Date of Birth
• High School Graduated from (include city and state)

• Date of High School Graduation

Education

• University /College Name
• City, State
• Major
• Minor
• Degree
• Anticipated Graduation Date
• Current Biology, Chemistry, Physics, and Math GPA (List each class)
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• MCAT Score
• Date MCAT was taken

• Are you currently enrolled in Princeton Review?

  • Yes
  • No
• Extracurricular Activities: List the extracurricular activities you have been in or are currently involved with and provide a description of your contribution to that activity. Also provide the calendar year(s) in which you participated in each activity.
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• Service (voluntary or paid): List your volunteer or paid work experience. Explain your specific responsibilities and date(s) completed or currently working.
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• Honors/Awards (BE SPECIFIC): List honors and awards you have received. Please do not list involvement in organizations and clubs unless you have been elected to an office or selected for a specific honor. Do not abbreviate award names, for example: National Honor Society - NHS. Also include the year(s) in which you received the honor or award.
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• Writing Entry: Please e-mail a personal statement of 500 words max about your background, interests, goals and why you want to become a physician.
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• Have you attended any medical school information sessions?

  • Yes
  • No

• I agree to stare my MCAT scores. This will only be for program information and not shared outside this office.

  • Yes
  • No

• Please send a copy of your transcript to: Southern KY AHEC Attn: Sherry Spragens PO Box 1770 Mt. Vernon, KY 40456