Mini-Med School Application Form

If you attended the Mini-Med School last year, please wait two years before reapplying.

Required fields are indicated by an * on the form below.

Salutation:

* First Name:
* Last Name:
* Community/UVA:
Department:
* Address:
(Line 2)
* City:
* State:
* Zip:
* Phone: (for example 434-924-3731)
Fax:
E-mail:
* Joint application: Yes No     If yes, with
Comments:
 
In past years, interest in the program has exceeded available space. Therefore, participants are selectd by a lottery from those applying to the program each year.