EQUIP Application for Admittance at the Associate Level (College/University Student)

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EQUIP Application for Admittance at the Associate Level (College / University Student)

Quillen College of Medicine
East Tennessee State University
The mission of EQUIP (Extending Quillen into Underserved areas through an Integrated Program) is to identify, mentor and train students as primary care physicians committed to rural and underserved medicine.

Qualifications
Must meet these criteria and supply proof when asked:

I am from a rural underserved community in the state of Tennessee, Southwest Virginia, or Northwest North Carolina.

I understand that EQUIP is a required minimum commitment of at least 2.5 years of time enrolled in the program prior to Medical School.

1. Legal Name:

2. Preferred Name:

3. Please list your preferred pronouns (optional):

4. Date of Birth:

5. Age at the time of application:

6. Current FULL Mailing Address:

7. Permanent FULL Mailing Address:

8. Email Address:

9. Cell Phone Number:

e.g. (999) 999-9999

10. Which high school did you attend?

11. Dates attended at your high school:

12. Colleges or universities that you have attended or are currently attending.

13. Dates you have attended or are attending the colleges or universities listed above.:

14. Degrees Awarded (if any)

15. What calendar year do you anticipate applying to medical school (keeping in mind that you apply one year prior to starting)?

16. What was your high school GPA?

17. What is your current GPA? / What is your science GPA?

18. Please choose one of the following prompts and upload your final essay here:

- Describe a rural or underserved experience that is unique to you. (1000 characters or less)
- Why is a primary care physician important to a rural or underserved community? (1000 characters or less)
- Think of an interaction that you have had with someone from a rural or underserved community that involved a health-related issue and describe how that impacted you. (1000 characters or less)

19. Tell us about your experience (please select all that apply):

Participation in the summer Rural High School Medical Camp at the Quillen College of Medicine.

Participation in a Remote Area Medical (RAM) event.

Shadowing a physician for 20 or more hours.

Volunteer work in a patient care area such as a hospital, long term care facility, EMS, and Physical Therapy for 20 hours or more.

Participation in high school or college sponsored activities such as athletics, band, and cheerleading.

Hold/Held leadership position in a high school or college sponsored organization.

Worked full-time in a rural community in a leadership position, educational field, health-related field, economic development, or other community service field.

20. If you checked "Worked full-time in a rural community in a leadership position, educational field, health-related field, economic development, or other community service field. (up to 30 points)" from the list above, please describe the full-time position and your responsibilities.

21. Please acknowledge the following by selecting the following options:

I understand that my participation in EQUIP does not guarantee acceptance into the Quillen College of Medicine and my AMCAS application will be held to the same standards as other applicants.

I understand that EQUIP has limited capacity and even though I may meet the application criteria I may not be accepted into the program.

If accepted into EQUIP I agree to participate in events periodically and respond to communications. Lack of participation may result in dismissal from the program.

If 18 years of age or older, I have signed the consent for the Quillen College of Medicine to publish media containing script and photos that may contain my participation in this program.

22. Type your full name here:

23. Digital Signature (please initial and provide last 4 digits of your social security number):

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