CUP AHEC Scholar Application 2022
Please complete the following questions to apply for the CUP AHEC Scholar program
Sign in to Google to save your progress. Learn more
First Name: *
Last Name: *
Please enter your university email address: *
Where is your hometown (town where you grew up)?
Which program are you enrolled in?
Clear selection
What is your expected year of graduation
Clear selection
On a scale of 1 (low) to 10 (high), how would you rate your interest in working as a health professional in a rural community?
Low
High
Clear selection
On a scale of 1 (low) to 10 (high), how would you rate your interest in working as a health professional in an urban underserved community?
Low
High
Clear selection
On a scale of 1 (low) to 10 (high), how would you rate your interest in working as a health professional in Maine?
Low
High
Clear selection
On a scale of 1 (low) to 10 (high), how would you rate your interest in performing a clinical rotation / practical experience in Maine?
Low
High
Clear selection
Describe your career goals/interests in working with rural or underserved populations. (250 words or less)
Ultimately, where do you think you would like to practice after graduation? (250 words or less) e.g. geographic location, urban/rural, setting type (preventative care, primary care, tertiary care, general practice, specialty care, independent or group practice etc).
Please describe the types of experiences you've had living and/or working in a rural area or with underserved populations. (250 words or less)
What do you hope to gain from the CUP AHEC Scholars program that will enhance your ability to work with rural or underserved populations? (250 words or less)
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of University of New England.

Does this form look suspicious? Report

Google Forms