Student Application – Doctors On Board Pipeline 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.

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

Yes No

If not, you can 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This authorization is continuous and may only be withdrawn by my specific rescission of this authorization.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

County (not Country)

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 Ethnicity/Origin/Country

Are you Native/Indigenous American Indian?

Yes No

Please list tribe(s)

Are you Hispanic/Latino?

Yes No

Please list Ethnicity/Origin/Country

Are you an other underrepresented minority?

Yes No

Please specify Ethnicity/Origin/Country

Name of High School/College/University

Year of High School/College/University

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

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

Gender Identity

Do you identify with the LGBTQ community?

Yes No

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

IMPORTANT

A headshot photo will be requested if you are accepted into the DOB/CHI Program. This photo will be used primarily for the closing ceremony and the team presentations. It may also be used in program and promotional materials. Make sure this photo is professional looking. No sunglasses, cars, inappropriate attire or gestures. Please make sure you are the only person in the photo. These photos may be seen by college/university program admissions and administrators. See sample image.

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

Doctors On Board
Program^®
and
Community Health
Internship

2022 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®andCommunity HealthInternship

2022 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
Community Health
Internship