2013 Detroit Pre-Medical Scholars Program Application

Complete application using a typewriter or complete the online application at http://miahec.wayne.edu.

|Applicant Information |
|Full Name: | | | |Date: | |
| Last |First |M.I. |
|Address: | | |
| Street Address |Apartment/Unit # |
| | | | |
| City |State |ZIP Code |
|Home Phone: |( ) |Cell Phone: |( ) |Emergency Contact Phone: |( ) |
|Date of Birth: | |E-mail Address: | |
|Best Way to Contact You: |MAIL |E-MAIL |PHONE |TEXT MESSAGE |
|Gender: |MALE |FEMALE | |Are you of Hispanic/Latino descent? |YES |NO |
|Race: | White/Caucasian | American Indian or Alaskan Native | Asian |
| | Black African American | Native Hawaiian or Other Pacific Islander | Other |
| | | | | | |
|Parental Information |
|Name of Mother: | |Name of Father: | |
|Mother’s Employer: | |Father’s Employer: | |
|Mother’s Phone Number: |( ) |Father’s Phone Number: |( ) |
|Is your mother a high school graduate? |YES |NO |Is your father a high school graduate? |YES |NO |
|Is your mother a college graduate? |YES |NO |Is your father a college graduate? |YES |NO |
| |
|Education |
|High School: | |Address: | |
|Last Semester GPA: |