About Utah AHEC
AHEC Scholars
Primary Care Summit
Utah Clinical Training
Contact Us
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About Utah AHEC
AHEC Scholars
Primary Care Summit
Utah Clinical Training
Contact Us
Instagram

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THE AHEC SCHOLARS PROGRAM:

AHEC Scholars Application

Applications for Fall 2021 will open in February 2021

Aplications for the Fall 2020 Cohort are now closed

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?*

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)*

This field should be left blank

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