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Personal Information

First Name*

MiddleName

Last Name*

Gender

Male

Female

Birth Month

Birth Date

Birth Year

Primary Undergraduate Institution

Name of School

Graduation Year

Permanent Address

Street Number

Street Number (continued)

City

State

Michigan County

Country

Zip Code

Evening Phone (including area code)

Email Address*

Race/Ethnicity

Please indicate whether you consider yourself to be Hispanic or Latino. (A person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)

Yes, Hispanic or Latino

No, not Hispanic or Latino

In addition, select one or more of the following racial categories to describe yourself:

American Indian or Alaska Native: a person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Asian: a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American: a person having origins in any black racial groups of Africa.

Native Hawaiian or Other Pacific Islander: a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Arab or North African

White: a person having origins in any of the original peoples of Europe

Citizenship Status

Will you be applying as?

Country of Citizenship

U-M Previous Affiliation

Uniqname

8 digit UMID (located on your MCard)

Area of Interest

What semester do you plan to begin your studies?

Have you ever attended or are you currently attending the University of Michigan?

Yes

If yes, which school or college?

How did you hear about us?

Communications from UM SPH

Email from U-M SPH

Letter from U-M SPH

Blog/website where you heard about U-M SPH

Event that you heard about U-M SPH at

Publications/Advertisement

Findings Magazine

U-M SPH brochure

Other

Faculty Referral

Alumnusa

ColleagueEmployer

Friend

Academic Advisor

Current UM SPH student

Other (specify below)

If you selected other above

Current student follow-up

Do you want to be contacted by a current University of Michigan School of Public Health student?

Yes

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