Providing Enrichment Activities and Academic Knowledge to Students interested in healthcare (PEAAKS)
Southwest Border AHEC PEAAKS (Providing Enrichment Academic Activities and Knowledge to Students Interested in Healthcare) program is designed for high school and university students who aspire to become healthcare professionals. PEAAKS promotes academic preparation and motivation for high school and college students through year-long sessions and summer programs designed to develop academically proficient and self-confident future health care professionals.
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Email *
Application 
School currently attending: *
Last Name: *
First Name: *
Age: *
City: *
County: *
Zip code : *
E-mail Address : ( must be GMAIL account ) *
Cell Phone: *
OPT IN FOR WHATSAPP GROUP: THIS IS OUR PRIMARY METHOD OF COMMUNICATION *
Are you a U.S. Citizen or Resident? *
Date of Birth: *
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Place of Birth: *
Population Group: *
Legal Guardian/Father's Legal Name: *
Legal Guardian/Father's Level of Education: *
Legal Guardian/Mother's Legal Name: *
Mother's  Level of Education: *
How many brothers and sisters do you have? *
I intend/plan/ would like to enter a health career: *
I intend/plan/would like to enter a health career in primary care ( such as Family Medicine Doctor nurse practitioner, Physician assistant , or community health worker, etc ) *
If no, list three other careers you are interested in? *
I intend/plan/would like to work with people who are medically underserved or where there is not enough healthcare. *
I intend/plan/would like to work in rural areas (not big cities): *
Did your parents claim you as a dependent on either of the last two year's income tax returns? *
Please provide the income range: *
Language spoken at home most of the time: *
In the past year, has lack of transportation kept you or any of your family members, from attending to medical appointments, work, school, or getting things needed for daily living? 
Clear selection
In the past year, have you or any family members you live with been UNABLE to get any of the following when it was REALLY NEEDED? Check all that apply.
Please explain in your own words, the development of your interest in health professions (e.g. medicine, dentistry, nursing, medical research, allied health, and others) and your reasons for wanting to become a health professional: *
Parental/Guardian Consent Form and Liability Waiver

As a parent or legal guardian, I remain legally responsible for any personal actions taken by the above named minor participant.  I agree on behalf of myself, my child named herein, successors and assigns, to hold harmless and defend the organizer, its officers, and directors and agents, and any other representatives associated with the PEAAKS program, from any and all actions, claims, demands, damages, costs, expenses, and all consequential damage arising from or in connection with my child attending the event or in connection with any illness or injury or cost of medical treatment in connection with therewith, and I agree to compensate the organizer, its officers, directors and agents, or representatives associated with the event for reasonable attorney’s fees and expenses arising therewith. 

Signature of Individual, Parent or Legal Guardian: (If younger than 18, PARENT OR LEGAL GUARDIAN MUST PRINT/SIGN on behalf of individual) *
MODEL AUTHORIZATION RELEASE FORM
For photographs, interviews, audio and video recordings
I voluntarily give my permission for UT Health Science Center staff and Southwest Border AHEC to record me {or my child or an individual to whom I provide guardianship) on video/audio tape, photographic film or any other medium including social media.

I authorize use of my {or my child's or an individual to whom I provide guardianship) name, likeness, voice and biographical material in Health Science Center publications and website -to include electronic and printed magazines, brochures, newsletters and the Internet and its social media {e.g., Facebook, Twitter, etc.)-as well as in its dissemination of information to the news media ------for publicity for the University and its programs.

I give the Health Science Center the right to exhibit or distribute such representations, in whole or in part, without limitations, for any educational purpose that the Health Science Center, and those acting under its authority, deem appropriate.

 I understand that I may withdraw or revoke my authorization at any time and such revocation must be given to the Health Science Center in writing. If I withdraw my permission, my image/information may no longer be used or released for the reasons covered by this authorization. However, I understand that any release made prior to a revocation may remain in public domain.  I further understand that no special favors, payment or any other compensation have been promised to me for agreeing to this authorization.
Signature of Individual/Model, Parent or Legal Guardian: (If younger than 18, PARENT OR LEGAL GUARDIAN MUST PRINT/SIGN on behalf of model) *
Date : *
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For help or more information please contact at:
PEAAKS Advisor- 830.758.1111 or email at peaaks@swb-ahec.org
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