Purposefully Pretty Inc.

PurposefullyPretty In Medicine Application Form

Outreaching, Teaching and Inspiring Young Women like You!

CONTACT INFORMATION

Your Name (required)

Permanent Address (required)

City,StateZipCode (required)

Home Phone (required)

Alternate Phone (required)

Your Email (required)

Date of Birth (required)

Current School (required)

Current Grade (required)

Why is the medical field your passion? (required)

Would you be interested in participating in the QHC or BHC volunteer program? If so, please specify which program and your availability. (required)

What area of the medical field are you most interested in?
Please tell us what area of medicine you would like to pursue (i.e; MD, DO, nurse, clinical social worker.
(required)

Would you be able to attend PPIM journal club and information sessions? (required)

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