Rural Manitoba Health Mentorship Program Application Form

Participant Name
First Name:
Last Name:
Participant Contact Information
Email Address:
Phone Number:
Address:
City:
Province:
Postal Code:
Do you live in a rural area, or have you lived in a rural area in the past?
 
 
Education
Name of University:
Degree in Progress:
Year in Program:
Have you taken the MCAT?  
 
AGPA:
GPA - Web Transcripts
Please attach your web transcripts indicating your current GPA (an adjusted GPA will be accounted for).

Attendance at Information Session
 
 
Clinical Experience / Other Relevant Experience
Please indicate any clinical experience you may have or other relevant work or volunteering experience, ie working/volunteering with children, research, etc.
Clinical / Other Experience #1 (maximum 50 words):
Number of Hours Completed per Week:
or per Month:
Number of Hours Completed in Total:
Clinical / Other Experience #2 (maximum 50 words):
Number of Hours Completed per Week:
or per Month:
Number of Hours Completed in Total:
Clinical / Other Experience #3 (maximum 50 words):
Number of Hours Completed per Week:
or per Month:
Number of Hours Completed in Total:
Personal Essay
Why have you decided to apply to this program, and what do you hope to gain from it? In particular, why are you interested in the rural aspect of this program? (maximum 300 words)
Reference #1
First Name:
Last Name:
Email Address:
Phone Number:
Job / Position:
Relationship:
Reference #2
First Name:
Last Name:
Email Address:
Phone Number:
Job / Position:
Relationship: