West Texas AHEC Application & Data Form

The WEST TEXAS AHEC Scholars Program recruits, trains, and supports a diverse group of students from across the state, creating a multidisciplinary team of health professionals committed to both community service and the transformation of health care in West Texas. We seek individuals who are committed to improving health and health care, devoted to community service, and interested in improving their own skills, and in working with other professionals in team-based care. With an emphasis on individuals from underrepresented minority populations and/or disadvantaged/rural backgrounds, as well as first-generation college students, the West Texas AHEC Scholars Program aims to improve the diversity and distribution of all health professions, and to support health systems transformation across the state. Each class of West Texas AHEC Scholars represents a variety of health professions and institutions from every region of West Texas. Selected applicants participate in a one to two-year educational program and may receive a $1600 stipend ($800 per year, subject to academic or institutional approval). Each AHEC Scholar will receive valuable experience and a West Texas AHEC Scholars Certificate, setting them apart from other students in an increasingly competitive environment. Selected scholars will meet students and faculty from other schools across the region, and state. They will also have the chance to meet leaders in health care and make connections with other participants, creating an invaluable network for their future careers.


Please fill in the information below to apply for the West Texas AHEC Scholars program. Your information will solely be used for the course registration and Health Resources & Services Administration grant reporting, and will not be shared with anyone other than the West Texas AHEC administration team and HRSA.

If you have any questions on course registration, please send an email to hstuteville@westcentraltexas.org.

Please complete all sections to the best of your knowledge.

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Email *
Student Email (.edu)
Full Name *
Date of Birth *
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DD
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What is your Gender?
 *
What is your Ethnicity? *
What is your Race? *
Required
What is your citizenship status?

Citizen, national, or lawful permanent resident of:
 *
Are you fluent in any other Languages besides English? 
Please specify the language(s) and your ability to speak, read, and/or write.
 *
What is your Veteran Status? *
Mobile Number with Area Code:
(xxx) xxx-xxxx
 *
What is/are your preferred method(s) of contact? *
Required
Current Street Address: *
Current City: *
Current State: *
Current Zip Code: *
Address you lived in at time of your high school graduation:

Street Address, City, State
 *
Is your hometown or current residence considered rural (County or Area with less than 50,000 residents)? *
While growing up, did you live in an area where there were few medical providers within a convenient distance?

MUC background
 *
Please select Yes below, if one or more of the following criteria applies to you:

• Person who is first generation to attend college.  

• Person whose high school has a low average SAT/ACT scores or below the average State test results.

• Person from a school district where 50 percent or less of graduates go to college.  

• Person who has a diagnosed physical or mental impairment that substantially limits participation in educational experiences.  

• Person for whom English is not his or her primary language and for whom language is still a barrier to academic performance.  

Does one or more of the criteria listed above apply to you?

 *
While growing up, did you or your family use federal or state assistance programs, such s free or reduced school lunch, subsidized housing, food stamps, Medicaid, etc.?

Economically Disadvantaged background
 *
Do you currently receive, or have you previously received, scholarships or loans for Disadvantaged Students?
 *
Did you obtain an NHSC (National Health Service Corp.) Scholarship? *
Name of academic institution you are currently attending: *
Current academic discipline or field of study: *
If attending Medical School, list Medical Specialty:

List all that apply.
 *
Current academic program and year

e.g. Bachelors, Year 3.
 *
What is the duration of your current academic program?

Can be described in semesters, months, or years.
 *
Date of expected academic graduation: *
MM
/
DD
/
YYYY
What degree are you expecting to earn? *
Highest level of education completed:

If postsecondary, list major(s)
 *
Previous College/University attended (if applicable) :

Name of academic organization, year of graduation. List as many as apply.
Please answer the following questions in regard to your Post-graduation (after graduation) intentions: *
Yes
No
Have you applied to a residency program?
Do you intend to apply for NHSC Loan Repayment?
Do you intend to become employed or pursue further training in a medically underserved community?
Do you intend to become employed or pursue further training in a primary care setting?
Do you intend to become employed or pursue further training in a rural setting?
Current Occupation: *
List college and high school activities (student government, sports, publications, school-sponsored community service programs, student-faculty committees, arts, music, etc.). List in descending order of significance. You will have space for eight college and four high school activities. *
List public service and community activities (homeless services, environmental protection/conservation, advocacy activities, work with religious organizations, etc.). Do not repeat items listed previously. *
What do you hope to do and what position do you hope to have upon completing the AHEC Scholars Program? *
Please list 3 references (Name, employer, phone, email):
 *
Tell us a few things you would like us to know about yourself, or questions you would like assistance with: *
The requirements of the West Texas AHEC Scholar Program are listed below. By checking all of the boxes you agree to, and understand that the program has been designed to meet the needs of those individuals who desire a challenging curriculum which prepares them for the workforce of the future. You are required to maintain a positive attitude and willingness to work, and organize your time. You are required to notify your instructor immediately if you fall behind. This statement acts as a commitment to follow through with any/all academic and discipline intervention plans deemed necessary for success. Acceptance into the AHEC Scholars Program is an invitation to work hard, to excel in all that you do, and to reach your full potential in every regard. By checking all of the boxes below you are stating you understand and agree to the following requirements: *
Required
I have read and understand the conditions of the AHEC Scholars Program as explained above. I affirm that I plan to utilize the training provided to pursue or enhance my educational experience and my career. I understand that the information in this application will only be accessible to AHEC staff in the course of their duties. If selected as an AHEC Scholar, I agree to the terms and conditions. I affirm the information contained herein is true and accurate to the best of my knowledge. By signing my name I agree to the terms. Please type in place of signature, and date below. *
Information for this form is provided voluntarily.  AHEC is required to report information about program participants.  Data will be kept private to the extent allowed by law, and will be referenced periodically to evaluate the effectiveness of AHEC services and programs.  We appreciate your cooperation in the completion of this form.  
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