Doctors
On Board
Program^®
and Internship

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.

Are you already enrolled in the Future Black Doctors National Registry?

Yes No

If not, please register at https://pmfmd.com/fbdnr/.

I/My parent/guardian 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This authorization is continuous and may only be withdrawn by my specific rescission of this authorization.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

Underrepresented Minorities in Medicine (URM) Who Want to Become Medical Doctors

Are you Native-born Black American?

Yes No

Are you African (origin in Black racial group)

Yes No

Please list Origin/Country

Are you Native American Indian?

Yes No

Please list tribe(s)

Are you Native-born Hispanic/Latino American?

Yes No

Are you Hispanic/Latino?

Yes No

Please list Ethnicity/Origin/Country

Other ethnicity?

Yes No

Please specify your Ethnicity/Origin/Country

Gender Identity

Female Male Prefer not to state Other

Do you identify with the LGBTQ community?

Yes No

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 describe the name and nature of the project.

Do you have any experience with:

PowerPoint Word Google Docs

Have you recieved any instruction in AI technology?

Yes No

If so, please specify. (ie. ChatGPT, Jasper, 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

How did you hear about this program

If Organization or other, please specify

The Physicians Medical Forum (PMF), founded in 2002 in Oakland, CA is a non-profit 501 (c) (3) organization.

Doctors
On Board
Program^®
and Internship

2025 Student Application

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

About

Programs

Scholarships

Other Info

Doctors On Board Program®and Internship

2025 Student Application

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

About

Programs

Scholarships

Other Info

Doctors
On Board
Program^®
and Internship