Application

Contact Information
First Name	Last Name
E-mail Address	Preferred Phone #

Background Information
School Year
Hometown	High School
University/College(s) (separate with commas)	Major(s) (separate with commas)

Mentoring Info/Preferences
I plan on applying to medical school
I have applied or plan to apply to these medical schools: (up to 7 schools separated by commas)
Mentor request(s) (e.g., male/female, Imi Ho`ola graduate, specific name) separated by commas: We will make every attempt to accomodate requests but cannot promise they will be honored.
I intend to participate in all program get-togethers
I intend to keep in touch with my mentor in other ways besides email
I anticipate needing a significant amount of mentoring this year
I would like to have a mock interview by a medical student this year
I would like to have my medical school personal statements reviewed by a medical student this year
Any other mentoring requests:

Please review your information (above) and read the following (below):
YES, I am interested in having a medical student mentor! As a mentee, I agree to make contact with my mentor at least ONCE A MONTH for the remainder of the academic year. This can be done via phone, email (emails must be returned within 7 days), or face to face. I will also meet my mentor on at least one occasion during this academic year. I also agree to pay the membership fee of $ 10 for this academic year.

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Questions? Email msmp.jabsom@gmail.com