GC-CREW 2023-24 Application

Contact Information

First Name

Last Name

Preferred Pronouns

Other Pronouns

Primary [non-academic] Email

Mailing Address (where you current reside)

Country

Street

City

Region

Postal Code

Permanent Address (if different from Mailing Address)

Country

Street

City

Region

Postal Code

Demographic Information

Gender

Race (check all that apply):

Are you Hispanic/Latino?

The National Institutes of Health (NIH) encourages institutions to diversify their student and faculty populations to enhance the participation of individuals from groups that are underrepresented in the biomedical, clinical, behavioral, and social sciences, including individuals from disadvantaged backgrounds. Individuals from disadvantaged backgrounds are defined as those who meet two or more of the following criteria. Please select all the statements that apply to you:

Backgrounds & Identities

I am currently or have been eligible for Federal Pell grants

I am currently or have been homeless

I am currently or have been in the foster care system

I am currently or have previously been eligible for the Federal Free and Reduced Lunch Program

I grew up in a U.S. rural area or a Centers for Medicare and Medicaid-designated Low-Income and Health Professional Shortage Area

I have a diagnosed disability (e.g. a physical or mental impairment that substantially limits or impacts major life activities)

I have received support for the Speical Supplemental Nutrition Program for Women, Infants, and Childhood (WIC) as a parent or child

As defined by the McKinney-Vento Homeless Assistance Act

As defined by the Administration for Children and Families

Click here for more information about Federal Free and Reduced Lunch Program

Click here for more information about designated rural areas, or here for more information about low-income and health professional shortage areas.

Click here for more information about the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

Is your primary language English?

What is your primary language?

I identify as part of the lesbian, gay, bisexual, transgender, queer, intersex, or asexual (LGBTQIA) community.

Would you like to specify?

Are you a first-generation college student?

NOTE: A student is considered first-generation if none of their parents or legal guardians completed a bachelor's degree program.

School Information

College/University:

Area of Study / Major:

Classification:

Unofficial Grade Point Average:

Graduation Month/Year (Actual or Expected):

NOTE: Your classification is not determined by the number of years of college coursework you have taken but [generally] by the number of semester hours you have earned, which may vary by institution. Please confirm your classification according to your school's policies/guidelines prior to submission.

Program Information

What term are you applying to?

Describe your educational and career goals?

Describe how your experiences and background fit in with our mission to increase diversity and accessibility to genetic counseling.

Are you currently in the process of applying to a Genetic Counseling graduate program (or considering applying to one in the future)?

Review & Submission

By entering your name in the signature box below, you are: Validating that the information you have provided on this application is accurate and truthful to the best of your knowledge. Confirming your willingness to share the information you have provided with MCW faculty and staff members involved with the selection and placement of GC-CREW applicants.

e-Signature:

Date: