Demographics/Background
 name
 phone
 email
 home adddress
 sex (m/f)
 age (birthdate?)
 race/ethnicity
 List the languages you use MOST often at home
 Facebook name
 Myspace name

School Info
 school name
 year/grade in school
 expected year of graduation
 major (if in college)
 List possible career goals
 List extracurricular activities
 Current GPA
 Did both parents finish college? (yes/no)

Interests
 I'm interested in HEALTH DISPARITIES because...
 If you were provided with a team of mentors from UAA and the community, what TWO health fields would you like your MENTORS to be from? (please check TWO)
 - Allied Health, Biomedical Research, Behavioral Health, Medicine, Nursing, Oral Health / Dentistry, Physician Assistant, Public Health, Social Work, Other (please specify)
 What health areas/topics would you like to be exposed to in research or practice?
 
