Pre-Health Advisory Committee (PHAC) Registration Form

Application for evaluation by the ODU Pre-Health Advisory Committee (PHAC)

Name Name * First Last
UIN *
ODU Email *
Date of Birth Date of Birth * / MM / DD YYYY
Gender

Gender Male Female Other
Are you of Hispanic or Latino?

Are you of Hispanic or Latino? Yes No
Select one or more of the following races:

Select one or more of the following races: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
What is your status at ODU? *

What is your status at ODU? Degree seeking 2nd degree Seeking post-bac
If you are seeking a degree, indicate the degree you are seeking, major, minor and expected
graduation date.
Applicant for: *

Applicant for: Medicine Osteopathic Medicine Veterinary Dentistry Pharmacy Physician Assistant Other Other
When do you plan on applying to professional school?
Overall GPA *
What year did you attend the Pre-Health Orientation?
Enter your grades in:
General Biology I Lecture
General Biology I Lab
General Biology II Lecture
General Biology II Lab
Foundations of Chemistry I Lecture
Foundations of Chemistry I Lab
Foundations of Chemistry II Lecture
Foundations of Chemistry II Lab
Experience
Volunteer hours (non-clinical)
Volunteer hours (clinical)
Internship hours
Scribing hours
Shadowing hours
Research hours
Healthcare work hours
Other (What's the experience/how many hours)
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7, 8, 9, 10 : the 2nd number is?