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AHEC
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AHEC
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AHEC
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THE
AHEC
SCHOLARS
PROGRAM
:
AHEC
Scholars Application
Applications for
Fall 2021
are
OPEN
now
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 2021–2022 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
Occupational Therapy Assistant
OTA
Mortuary Sciences
Associate in Nursing
Radiologic Technology (Rad Tech)
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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