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Education & Research > Trainee Programs > Scholars' Program > Scholars' Program Nomination Form - BIPOC Candidate

Scholars' Program Nomination Form - BIPOC Candidate (1)

Thank you for your interest in the Scholars' Program. Please fill out the required information below.

Ensure that all documents are submitted in PDF format and contain no special characters in the file name, including punctuation.

NOTE: This online form must be completed in one single session. This form cannot save your information to return to at a later time.

BIPOC Candidate (May Submit One)

Must be a Medical Student Y3-Y4 or Adult Program Resident PGY1-PGY2 or Pediatric Program Resident PGY1-PGY3.

Candidate must also be a CAG member or have applied to become one by October 21.

Candidate Salutation
 Dr.
 Mr.
 Ms.
 Mrs.
 Mx.
Candidate Gender
 Man
 Woman
 Non-Binary
 Other:
Candidate is
 Medical Student    Resident (Adult)    Resident (Pediatric)

In your Letter of Intent, please also include in your own words, how would you describe your racial or ethnic heritage as a BIPOC candidate.

Electronic Signature

By checking this box and typing my name, I certify that I am the person accessing this webpage, submitting this form and that all information on this form is true and correct.

I also agree that the checkbox and my name typed below are to be used as my electronic signature.

I certify that the above information is true and correct and that I am the person completing this form.

 Yes  

Please ensure that all required fields are filled out correctly.

Upon successful submission, you will be redirected to a confirmation webpage. If this does not occur, please contact the .

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