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AHEC
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THE
AHEC
SCHOLARS
PROGRAM
:
AHEC
Scholars Application
Applications for the Fall 2020 Cohort are due by September 30, 2020.
First Name
*
Last Name
*
Date of Birth
*
Permanent Address
*
City
*
State
*
Zip Code
*
Phone Number
*
Email address
*
University
University
ID
*
What is your identified gender?
*
Male
Female
Prefer to self describe
Prefer not to answer
Describe your gender:
*
Where did you grow up?
*
Urban Area
Rural Area
Prefer Not to Answer
From which high school did you graduate?
*
City
*
State
*
Ethnicity
*
Hispanic/Latino
Not Hispanic/Latino
Prefer Not to Answer
Race (check all that apply)
*
Black or African American
Native Hawaiian or Pacific Islander
White
American Indian or Alaska Native
Asian
Other
Prefer Not to Answer
Other Race
Military Status (check all that apply)
*
Not a Veteran
Veteran
Disabled Veteran
Special Disabled Veteran
Other Protected Veteran
Can you answer yes to any of the following?
*
Yes
No
You are (or will be) the first generation in your family to attend college
You currently receive a scholarship or loan for disadvantaged students
While growing up, you or your family used a federal or state assistance program (i.e., free or reduced school lunch,
WIC
, subsidized housing, food stamps, Medicaid, etc.)
While growing up, you lived where there were few medical providers at a convenient distance
Student Status:
*
Part-Time
Full-Time
What is your current academic year?
*
Please select
1st Year
2nd Year
3rd Year
4th Year
5th Year
Which degree programs will you be enrolled in during the 2019–2020 year? (select most applicable)
*
Doctor of Dental Surgery
Bachelor of Science Dental Hygiene
Doctor of Nursing Practice
Bachelor of Nursing
Master of Physician Assistant Studies
Master of Public Health/Master of Science in Public Health
Master of Health Administration
Bachelor of Social Work
Master of Social Work
Doctor of Medicine
Other
What is your expected date of graduation?
*
How did you hear about the
AHEC
Scholars program?
The following activities are required components of the
AHEC
Scholars Program: the
AHEC
Scholars Mentor Dinner on October 15, 2020 and Online or In-person Book Club meetings. Are you available to attend all required activities?
*
Yes
No
How would you rank your desire to work in an underserved urban or rural community after completion of your training program?
*
Very Likely
Somewhat Likely
Somewhat Unlikely
Very Unlikely
Undecided
Which of the following would interest you? (Check all that apply.)
*
Rural Experience
Underserved Urban Experience
Inter-Discipline Student Networking
Professional Mentoring
Professional Networking
Other
Please describe:
*
Please describe any previous opportunities providing service in a community setting. (500 max)
*
What do you perceive to be the challenges associated with healthcare in rural and underserved populations? (500 max)
*
Why is interprofessional collaboration important for the future of healthcare? (500 max)
*
Send
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