Doctors
On Board
Program^®

In 200 words or less, please explain why you want to become a medical doctor (M.D.):
*Please include what type of doctor you may want to be and why.

I/My parent/guardian (if 18 years or under) hereby authorize(s) the Physicians Medical Forum (PMF) to use, reproduce, and/or publish photographs, films and/or videos that may pertain to me—including my image, likeness and/or voice without compensation. I understand that this material may be used in various publications, public affairs releases, recruitment materials, broadcast public service advertising, fundraising or for other related endeavors. This material may also appear on PMF’s Internet web page, press releases, Facebook, YouTube, Instagram and other social media.

I/My parent/guardian hereby release(s) Physicians Medical Forum, and any of its associated or affiliated companies, their directors, officers, agents, employees and customers, and appointed advertising agencies, their directors, officers, agents and employees from all claims of every kind on account of such use.

This authorization is continuous and may only be withdrawn by my specific rescission of this authorization. Consequently, PMF may publish materials, use my name, photograph, and/or make reference to me in any manner that PMF deems appropriate in order to promote/publicize its mission.

Yes No

Gender Identity

Female Male Prefer not to state

County (not Country)

Name of High School/College/University

Year of High School/College/University

Have you received any scholarships?

Yes No

If so, name of scholarship and how much?

What tests have you have taken, if any? (Check all that apply)

Have you taken any of the following classes? (Check all that apply)

Please list additional STEM classes

Have you participated in a research project?

Yes No

Was it a team or individual project?

Team Individual

If so, please beifly provide the name, type and description of the project.

Do you have any experience with:

If other, please specify.

Have you recieved any instruction in AI technology?

Yes No

If so, please specify. (ie. ChatGPT, Jasper, Gemini, Grammerly)

Are you in a Post-Bac Program?

Yes No

Specify Year

Year 1 Year 2 Not Applicable

What type of doctor do you think you would like to be? (Please check all that apply)

If Other, please list

Marital Status

Single Married Divorced

Note: If you are under 18 years old, you must provide the following info:

Parent/Guardian Name(s)

Parent/Guardian Email

Parent/Guardian Cell

PARENT/FAMILY WORKSHOP

As an integral part of the team preparing and inspiring you towards your goal of becoming future physicians, we would like to invite your parent/guardian/family members to attend the Parent and Family Workshop & Awarding of Student Certificate held during the “Doctors On Board Program.”

NOTE: All attendees must be an adult at least 21 years or older. This application can register up to 2 attendees. Please no children under 21 years old.

If accepted into the program, do you have family member who wish to attend the Parent and Family Workshop?

Yes No

If yes, please add their information below and workshop information will be sent to them if you are accepted into the program.

NOTE: This information will ONLY be sent if you are accepted into the program.

First parent /guardian / family attending

Second parent /guardian / family attending

How did you hear about this program

If Organization or other, please specify

Doctors
On Board
Program^®

2026 Student Application

We are no longer accepting applications for the 2022 program. Thank you for your interest.

Authorization

PARENT/FAMILY WORKSHOP

First parent /guardian / family attending

Second parent /guardian / family attending

About

Programs

Scholarships

Other Info

Doctors On Board Program®

2026 Student Application

We are no longer accepting applications for the 2022 program. Thank you for your interest.

Authorization

PARENT/FAMILY WORKSHOP

First parent /guardian / family attending

Second parent /guardian / family attending

Doctors
On Board
Program^®