Penn State Hershey College of Medicine Student Information Form

First Name:   Last Name:      Gender: Female  Male

Phone No.:    Email:

Hometown:    State:      Country:

Degree Program: MD  MS  MD/PhD  PhD     Name of Program (ex. physiology):

Undergraduate Degree:  BS  BA  Other  

Name of College/University:   Year Graduated:

City:   State:      Country:

Name of College/University:   Year Graduated:

City:   State:      Country:

Name of High School:      Year Graduated:

City:   State:     Country:

***If you would like Marketing and Communications to send information about your enrollment at Penn State College of Medicine to a specific hometown newspaper(s), please list information below. If possible, provide a mailing address and email address. Also, list the full name of the newspaper (Ex: “The Reading Times” rather than “The Times.”).

1. Newspaper: Address:   Email:
2. Newspaper: Address:   Email:
3. Newspaper: Address:   Email:

By clicking the Submit button below, I hereby consent that the information listed on this form may be used by Penn State College of Medicine to promote my activities and achievements as a student, as well as to promote the College of Medicine and its programs.