EQUIP Doc For a Day

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Doctor For a Day

Quillen College of Medicine
East Tennessee State University

Application Deadline: April 25th, 2025

Last Name

First Name:

Street

Address 2 (Apt, Unit Etc.)

City

County

State

Zip Code

Email Address

Date of Birth

e.g. 99/99/9999

Phone Number

e.g. (999) 999-9999

High School

Are you currently a sophomore in high school?

High School GPA

Guidance Counselor Name

Guidance Counselor Phone

e.g. (999) 999-9999

Guidance Counselor Email

OPTIONAL: Do you identify with any of these groups which may be considered underrepresented in medicine? This optional information can help us plan activities and support services for the program.

Race or Ethnicity

Hispanic or Latino

African American

Asian American

Native American

Other person of color or multiracial

OPTIONAL: Disadvantaged background: (Check all that apply)

Grew up in a rural or Appalachian area

Immigrant to the United States

First generation college student (neither of your parents earned a degree beyond high school)

OPTIONAL: Gender – This optional information can help us plan activities and support services for the program.

Why do you consider yourself rural (Maximum 500 words)?

Any admitted student who would like to request accommodations should contact ETSU's Disability Services office by phone (423-439-8346) or by email (littleme@etsu.edu) prior to the start date of Doc for a Day. Additionally, Disability Services can provide assistance for any applicant that may require accommodations during the admissions process.

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