Personal Information
First and Last Name
Date of Birth
MM/DD/YYYY
Street Address
City, State, and Zip Code
Phone
Email
How do you identify?
Please select...
She/Her
He/Him
They/Them
Prefer not to answer
Do you consider yourself an Under Represented Minority?
Please select...
Yes
No
Prefer not to answer
What race or ethnicity describes you?
Please select...
American Indian
Asian/Pacific Island
Black or African American
Hispanic
White/Caucasian
Multiple Ethnicities/Other
Prefer not to answer
Are you interested in?
Please select...
4th yr. Sub I Rotation
URM Rotation
Education
School
School Contact
School Phone
School Email
Questionnaire
Please tell us why you are interested in LGH.
What is your current level of interest in Family Medicine?
What experience have you had so far in Family Medicine?
How much do you know about Lancaster and the diverse population we serve?