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Center for Health Sciences
Rural Medical Education
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Student Information Form

If you are interested in local and hometown publicity about your rural rotations, please complete this form. The information will be distributed to media in your hometown and rotation community.

If you prefer not to be included, please complete the OPT OUT section at the bottom of this form and submit.

Personal Information
First and Last Name: Email:  
 
Home Town and State:    
   
High School: Location: Year Graduated:
Undergraduate School: Location: Year Graduated:
Degree Received:
Parent Information: Please provide the home city and state for each person you list.
Grandparent Information: Please provide the home city and state for each person you list.
 
Future Medical Plans
 
Additional Information
Organizations, Clubs, Committees, etc:
Awards, Presentations, Publications:
Community Service:
Other Information You Would Like Included in a News Release:
 
I give permission to OSU-CHS to distribute my photo to media outlets.
I DO NOT give permission to OSU-CHS to distribute my photo to media outlets.
 

Opt Out Choice

First and Last Name: Home Town and City:  
 
Opt Out (I choose not to have my information published)

 

Please make sure you click submit,
otherwise your test will not be submitted properly.