Medical Scholars Program Application

What you'll need to apply:

1. HIPAA Training Manual for Student Observers
Click here to download the PDF HIPAA Manual. Read and understand the tutorialcall or contact us if you have any questions.

2. Shadowing Program Confidentiality HIPAA Form
Click here to download the PDF form. Please complete this form as an acknowledgment of HIPPA confidentiality, sign it, then upload it with the application as a PDF or JPG (less than 2mb).

3. Observer-Sponsor Acknowledgement Form
Click here to download the PDF form. After reviewing, please fill in and sign the "Observer Name" and "Signature" only, then upload it with the application as a PDF or JPG (less than 2mb).

4. Two paragraph essay explaining why this experience will be important/relevant to you.
You may want to give some thought to your two paragraph essay before you begin the application form.

Contact Information

Have you previously applied for, or participated in, the Summit Medical Group Foundation Medical Scholars Program? *

Parent/Legal Guardian Name & Emergency Contact Info
Preferences

If you are approved to participate in the Medical Scholars Program which area of medicine are you most interested in?

Please indicate which day of the week is best to participate in the program (Any special scheduling requests can be listed in the additional comments. Efforts will be made to try and accommodate requests but can’t be guaranteed.) *

Resume and Essay

Upload a resume

Required Documents

Upload your signed "Shadowing Program Confidentiality HIPAA" Form *
(* jpg or pdf accepted. File must be less than 2MB in size)

Upload your signed "Observer-Sponsor Acknowledgement" Form *
(* jpg or pdf accepted. File must be less than 2MB in size)

Additional Notes and Questions

Note: Transportation to/from the SMG campus is not provided.

Would you like to subscribe to our mailing list? *

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