College of Medicine: New Student

Curricula Information
Semester
Academic Year
Class
MDPhD	Is this student a new MDPhD student? Yes No
Student Information
SSN (123456789)
Last Name
First Name
Middle Name
Date of Birth (16-MAR-1985)
Residency	Is this student a Vermont resident? Yes No
Contact Information
Address
City
State/Province
Zip/Postal
Phone (802.656.2045)
Email Address
Biographical Information
Gender
US Citizen	Is this student a US citizen? Yes No
Race/Ethnicity	Is this student Hispanic or Latino (including Spain?) Yes No Does the student identify with one or more of the following groups? Please select all applicable groups. American Indian or Alaska Native (including all Original Peoples of the Americas) Asian (including Indian subcontinent and Philippines) Black or African American (including Africa and Caribbean) Native Hawaiian or Other Pacific Islander (Original Peoples) White (including Middle Eastern)
Military Status	Active Inactive Dependent Veteran Status
COM Contact Person's Email Address: