Rose-Hulman Preliminary Medicine Club

Membership Application

Notice:  None of the information filled out in this form will be explicitly given to any other website.  Also, the information in this document is not encrypted; therefore, no information that needs to be kept private should be presented in any of the following fields.  Lastly, all fields that have a * are required fields.  Once again report any problems to the webmaster.  The application can also be printed out and returned to CM 963.

First Name*     Middle Initial*          Last Name*

Sex*                    Country*     State    City

Year*        Major*          Phone Number*    E-mail*

Survey Questions:

Do you intend to attend Medical School after Rose-Hulman?  Yes    No

Are you interested in Research or Primary Care (help)?

Are you interested in doing research at Rose-Hulman? Yes   No

Which type of doctor are you interested in possibly becoming (help)?

What are some of your interests?

Do you wish to receive e-mails from the club about upcoming events and opportunities? Yes  No