Utah AHEC Student Application Form

Minimum requirements: Applicants should currently be in good academic standing and must have completed a minimum of their first year in their educational program. Placements are arranged in rural and urban medically underserved sites. Most urban placements are coordinated through the National Health Service Corps Utah SEARCH program.

To consider this application, it must be filled out accurately and completely and include a written statement describing your interest in participating in an AHEC and/or SEARCH training opportunity. Applications must be submitted 6 weeks prior to placement start date. You may also send questions or comments to us at: leslie.read@hsc.utah.edu


Student Name:
Mr. Mrs. Ms. Dr.
University/Institution/Medical Residency Program:
College/Department:
Program/Discipline:  
Current year of training:  
Course Instructor:  

Demographic Information
Student's ID number:
 

Current Address:

Street:
City:
State:
Zip:
Phone:
Day:
Evening:
Pager:
E-mail:

Permanent/Parent's Address:

Street:
City:
State:
Zip:
Phone:
Day:
Evening:
Date of Birth:
Gender: Male   Female
Your main ethnicity: American Indian or Alaska Native
Underrepresented Asian (NOT Chinese, Japanese, Korean, Thai, Phillipino, Asian Indian)
Asian
Black/African American
Hispanic or Latino
Native Hawaiian or Pacific Islander
White, Disadvantaged
White, Non-Disadvantaged
Other
 
Level of education Residency
Post-graduate
College Undergraduate
Vocational/Technical
Marital status Single Married
Number of children

Ages:

Student's geographic background Urban Rural

Are you from a disadvantaged background? Yes No

If yes, please explain:

Projected graduation date:
This is my first AHEC training experience: Yes No
National Health Service Corps Scholar? Yes No

Site Information
Hours/Week
    Total hours

Preferred Dates:
Start
End

My Preceptor has already been identified: Yes No
Preferred Preceptor and Utah location:
Preceptor
Location
My preceptor has already been contacted: Yes No

If yes:
Preceptor's name:
Preceptor's address:
Preceptor's city, state, and zip code:
Preceptor's phone:

Housing Requirements: (Lodging is provided for students training in rural sites and for NHSC Scholars coming from states other than Utah in urban sites.)
I will need assistance arranging for lodging: Yes No
If yes, for: Self Spouse children
Please describe your interest in clinical training in rural and other medically underserved communities. In essence, please describe reasons you are interested in this training opportunity, as well as a summary of personal background information that will assist you in making this a positive clinical training experience.
Please describe any special needs you may have:
I will fax a resume and a statement explaining my interest in an AHEC training opportunity to Leslie Read: (801) 585-9580


    
Submit application at least 6 weeks prior to placement dates