STEPS Program

Application for 2024-2025

Question Title

* 1. DEMOGRAPHICS:

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Cell Phone Number

Question Title

* 2. COLLEGE INFORMATION

Current College:

Classification:

City:

State:

Major:

Minor:

Degree:

Anticipated Graduation Date:

Current GPA:

MCAT Score:

Date MCAT was taken:

If MCAT not taken yet or plan to take it again please give an anticipated date:

Question Title

* 3. MOTHER/GUARDIAN INFORMATION

Name:

Address:

City:

State:

Zip/Postal Code:

Home Phone:

Cell Phone:

Email Address:

Question Title

* 4. FATHER/GUARDIAN INFORMATION

Name:

Address:

City:

State:

Zip/Postal Code:

Home Phone:

Cell Phone:

Email Address:

Question Title

* 5. EMERGENCY CONTACT INFORMATION

Name:

Relationship:

Home Phone:

Cell Phone:

Email Address:

Please explain any special circumstances you would like to be known in considering you for the STEPS Program (e.g. personal learning/physical disability, lengthy family illness, disabled parent, etc.):

Question Title

* 6. SHADOWING FOCUS AREA: What are your top 2 choices

Family Medicine
Internal Medicine
Emergency Medicine
Nephrology
Oncology
Urology
Psychology
General Surgey
Radiology
Rehabilitation
Pathology
Podiatry
Gastroenterology
Other:

Question Title

* 7. STUDENT PROFILE

Extracurricular Activities: List the extracurricular activities you have been in or currently involved and provide a description of our contribution to that activity. (Additional page may be attached if needed):

Service (voluntary or paid) List your volunteer or paid work experience. Explain your specific responsibilities and date(s) completed or currently working. (Additional page may be attached if needed):

Honors/Awards (BE SPECIFIC) List honors and/or awards you have received. Please do not list involvement in organizations or clubs unless you have been elected to an office or selected for a specific honor. Do not abbreviate name, for example: National Honor Society - NHS. (Additional page may be attached if needed):

Writing Entry: Include a personal essay of 500 words about your background, interests and goals. This allows the application review committee to get a better understanding of the student's personality and expectations. Type on a separate document and double-space your writing entry and attach to the application.

Question Title

* 8. STUDENT CONSENT AND AGREEMENT: By my signature below, I hereby certify that the information provided is true and accurate to the best of my knowledge and that the writing entry is my original work. I commit myself to abide by the rules and expectations of the STEPS Program.

Name:

Date:

All application documents must be received by September 30, 2024. Application must include the following in order to be considered for the STEPS Program: 1.) Copy of college transcript 2.) Letter of recommendation from college faculty 3.) Completed STEPS Program application 4.) 500 word essay (why you want to become a DO or MD) typed, double spaced.

Email documents to Kathleen.Couch@kctcs.edu by the deadline with the subject line STEPS Program