Application: Minority Introduction to the Health Sciences (MITHS)

Student Information

Last Name

First Name

Telephone

Address

City

State

Zip Code

Date of Birth

Place of Birth

Race/Ethnicity

Are You a U.S. citizen?

Yes

Upload copy of birth certificate or passport

Please attach a copy of birth certificate or passport if you are a U.S. citizen.
One file only.
2 MB limit.
Allowed types: pdf.

Are you a legal resident or DACA participant?

Yes

Upload copy of green card or DACA Card

Please upload a copy of your green card if you are a legal U.S. resident.
One file only.
2 MB limit.
Allowed types: pdf.

Upload 4x4 (image size) headshot

Photo must be 4 inches by 4 inches
One file only.
2 MB limit.
Allowed types: gif, jpg, jpeg, png, tif, tiff.