HMED Application

First Name

Last Name

Last four digits of your GID:

Professional e-mail address that can be used to contact you:

Phone Number:

What profession(s) are you interested in?

If you answered "other or more than 1" on the last question, please specify:

What semester(s) are you interested in taking this course?

What courses will be completed BEFORE taking this course? (select all that apply)

What is your current GPA?

4.0-3.8

3.79-3.6

3.59-3.3

3.29-3.0

less than 3.0

How much observation or shadowing experience do you have already?

more than 100 hours

100-80

79-50

49-20

19-10

less than 10

Where are you interested in completing this experience? (select all that apply)