Medical Horizons 2026 APPLICATION

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ETSU ~ Quillen College of Medicine ~ Ballad Health
2026 Medical Horizons Program **APPLICATION DEADLINE: March 13, 2026**

Date of Program: June 1 - 26, 2026

Applicant Information

Last Name

First Name

Middle Initial

Address

Apartment/Unit #

City

State

Zip Code

Phone:

Email Address:

Cell Phone (if applicable)

ETSU ID# (if applicable)

Current Career Goal

Date of Birth: (Applicant must be 18 years or age or older by June 1, 2026)

Areas of medical specialty you are interested in?

Yes

Have you previously applied to this program?

If "Yes", what year?

Yes

Are you a citizen of the United States?

Are you authorized to work in the U.S.?

Have you ever worked for Balled Health or ETSU?

If "Yes", when?

Job Title and Description (if previously worked)

Yes

Are you currently under indictment, or have you ever been convicted of a felony or misdemeanor other than a minor traffic violation?
(NOTE: Hospitals and clinics MAY require a clean background check prior to admission to their facility)

If "Yes", explain fully

Reasons why you want to attend this program (REQUIRED)

IN CASE OF EMERGENCY (ICE) Information

FIRST NAME

LAST NAME

RELATIONSHIP

First

Last

who

Phone

Education

Please complete all that apply - past and present

School / college -
Please complete all that apply

Name of school or college

Year in school/college (choose
the one that applies currently)

Graduation date

Major and degree (if applicable)

High School

Technical College

College

Other School / College

Graduate College

Post Graduate College

Not Currently in School

Current / Previous Employment

Company / Organization

Phone

Address

Supervisor

Job Title

Responsibilities

From

Reason For Leaving

Experience (REQUIRED)

List any significant extracurricular or experiential activities

ETSU Housing (Optional)

Arrangements and expenses for ETSU Guest Housing are the responsibility of the student enrolling in the Medical Horizons program.

ETSU offers housing options for those who need it (APPLY EARLY as rooms go fast). Please contact ETSU Housing directly for pricing & availability at this link - https://www.etsu.edu/students/housing/faq/guesthousing.php.

ETSU requires a letter from me confirming your acceptance into our program, which is sent after the Selection Committee has made the decision.

** Please indicate below if you plan to utilize ETSU Guest Housing. **

Yes, I plan to use ETSU housing

No, I will make my own arrangements for housing

Health Insurance (REQUIRED)

Proof of Health Insurance is required BEFORE orientation (copy - front /back) for the safety of student during this program.

Health Insurance Carrier

Name of primary insured person (If you are a dependent)

Upload Health Insurance (front)
Formats accepted: JPG, PNG and PDF

Upload Health Insurance (back)
Formats accepted: JPG, PNG and PDF

Disclaimer and Signature

If accepted, I agree to participate fully in all aspects of the Medical Horizons Program as directed by the Program Director or designee for the whole 4 weeks of this program. (If working, I will make plans to be available - 8a to 5p.)

I also understand and agree to complete any and all instruction and training as may be required by Ballad Health and or ETSU, including but not limited to HIPAA, OSHA, Emergency Preparedness, and other forms before participating in this program.

Student and student's parent(s)/guardian (if applicable) agrees at all times to be responsible for the actions of the student in conjunction with this agreement and understand that Ballad Health, James H. Quillen College of Medicine of East Tennessee State University and its employees and agents shall have no liability for the actions of the student and further agree to waive all rights of action for any injury or illness that the student might incur in conjunction with this agreement even if such injury or illness is believed to result from the negligence of Ballad Health, James H. Quillen College of Medicine of East Tennessee State University or their employees or agents.

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to acceptance into the MH program, I understand that false or misleading information in my application may result in my denial or dismissal.

Type your full name here (this will serve as your digital signature):

Immunization Records (Proof is REQUIRED - include now OR if accepted into program.)

Vaccine

1st

2nd

3rd

4th

DPT (3 doses)

Polio (OPV / IPV) (3 doses)

Hepatitis B (3 shot series)

MMR (1 post - 1980)

PPD - Tuberculin Skin Test (doesn't expire before 6-1-26)

Tetanus (1 dose< 10 yrs)

Influenza (current) or sign medical waiver

NOTE: Vaccine exemption forms available upon request

History of Varicella (aka: Chickenpox) - Date

Immunization Record 1
Formats accepted: JPG, PNG and PDF

Immunization Record 2
Formats accepted: JPG, PNG and PDF

My immunization records will be EMAILED PDF to Bettina by MAY 18, 2026.

Application Deadline: March 13, 2026

Thank you for your interest in our Medical Horizons Program. This application will automatically be sent to the Medical Horizons Coordinator for review.

Bettina Cannon, Coordinator

Medical Horizons Program

Department of Surgery
Box 70575
Johnson City, TN 37614

Email: cannonbg@etsu.edu

For more information go to: http://www.etsu.edu/com/sa/admissions/medicalhorizons/

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