2013 Detroit Pre-Medical Scholars Program Application Complete application using a typewriter or complete the online application at http://miahec.wayne.edu. |Applicant Information | |Full Name: | | | |Date: | | | Last |First |M.I. | |Address: | | | | Street Address |Apartment/Unit # | | | | | | | City |State |ZIP Code | |Home Phone: |( ) |Cell Phone: |( ) |Emergency Contact Phone: |( ) | |Date of Birth: | |E-mail Address: | | |Best Way to Contact You: |MAIL |E-MAIL |PHONE |TEXT MESSAGE | |Gender: |MALE |FEMALE | |Are you of Hispanic/Latino descent? |YES |NO | |Race: | White/Caucasian | American Indian or Alaskan Native | Asian | | | Black African American | Native Hawaiian or Other Pacific Islander | Other | | | | | | | | |Parental Information | |Name of Mother: | |Name of Father: | | |Mother’s Employer: | |Father’s Employer: | | |Mother’s Phone Number: |( ) |Father’s Phone Number: |( ) | |Is your mother a high school graduate? |YES |NO |Is your father a high school graduate? |YES |NO | |Is your mother a college graduate? |YES |NO |Is your father a college graduate? |YES |NO | | | |Education | |High School: | |Address: | | |Last Semester GPA: | Show More
