dei scholarship form

Emergency Medicine: Diversity, Equity and Inclusivity Scholarship Form
To be eligible, the applicant must:
- be from a historically underrepresented group
  - African American/Black
  - Asian: Filipino, Hmong or Vietnamese
  - Hispanic/Latinx
  - Native American/American Indians
  - Alaskan Native
- Complete scholarship form in its entirety
- Be a MS4 interested in emergency medicine
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student E-mail
example@example.com
Phone Number
What does diversity, equity and inclusion mean to you? (250 words)
How will receiving this scholarship impact you? (250 words)
Why does the EM residency at Northeast Georgia Medical center interest you? (100 words)
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