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Office of Admissions, M1-103
UMKC School of Medicine
2411 Holmes
Kansas City, MO 64108
Phone: 816-235-1870
Email: medicine@umkc.edu

Saturday Academy Application 2020

PERSONAL INFORMATION:

First Name:*

Last Name:*

Middle Name/Initial:

Address:

Street Address City State / Province / Region Postal / Zip Code

Telephone:*

Area Code

-

Phone Number

E-mail:*

Date of birth (mm/dd/yy}:

Gender:

Male

Female

Non-binary or Gender non-conforming

Are you Hispanic/Latino?

Yes

No

Which of the following do you consider to be your racial background? Please check all races that apply:

Race Options

American Indian/Alaskan Native

African American/Black

Asian (underrepresented)

Asian (includes Chinese, Filipino, Japanese, Korean, Asian Indian or Thai)

White/Caucasian

Native Hawaiian or Other Pacific Islander

Not Specified

EDUCATION INFORMATION:

Name of school:

Grade:

Is student taking, or previously taken: Biology, Chemistry, Algebra?

Yes

No

If yes, please specify

PARENT/GUARDIAN INFORMATION AND CONSENT:

Parent/Guardian Name(s):

Address (if different from yours)

Per the above, are you the _____ (please select one)

Parent

Guardian

Parent/Guardian E-mail:

Parent/Guardian telephone:*

Area Code

-

Phone Number

Where does your Parent or Guardian work?

SUPPLEMENTAL QUESTIONS:

Why are you interested in participating in Saturday Academy? What do you hope to get from the program?

Will you participate in tutoring from 9:00 a.m. to 10:00 a.m.?

Yes

No

What health care career field are you most interested in exploring?

Rank order which health care career field you are most interested in exploring. (1 indicates your greatest interest / 5 indicates the least interest)

Medicine:

Nursing:

Pharmacy:

Dentistry:

Other:

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UMKC School of Medicine

2411 Holmes Street
Kansas City, Missouri 64108
Phone (Main): 816-235-1808
Fax: 816-235-5277
Email: UMKCMedWeb@umkc.edu
Admissions: (816) 235-1870

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© Curators of the University of Missouri. DMCA and other copyright information. University of Missouri-Kansas City | Kansas City, MO 64110 | (816) 235-1000
UMKC is an equal opportunity/access/affirmative action/pro-disability and veteran employer and does not discriminate on the basis of sex in our education programs or activities, pursuant to Title IX and 34 CFR Part 106. For more information, visit our UMKC Statement of Nondiscrimination. Issues with this website?