Medicine, Health, and Society
Student Information Form
Name _________________________________________
Exp Grad Year ________________
E-mail address ____________________________________________________________
Do you have a 2nd major? ________________________________________________
Have you declared a minor? _________________________________________________
If you are an MHS minor, what is your major? ___________________________________
Do you identify yourself as pre-heath profession? If so, what profession? _______________
Are you planning to pursue post-secondary education? If so, what type school are you
planning to attend?
Law School
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Medical School
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Nursing School
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Graduate School (discipline?) _______________________________________
Info about MHS-related extra-curricular interests, activities, volunteering:
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Projected career goals:
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