AHEC Scholars Host Site Application

2026 AHEC Scholars Health Center Host Site Application

If your clinic site would like to be a host site for the AHEC Scholars Program, please complete this application by September 4, 2026 by 11:59pm. You will be asked to upload a completed copy of the 2026 AHEC Scholars MOA in the application below.

AHEC Host Site Application

"*" indicates required fields

Contact Information

Health Center Organization*

Name*

First Last

Title*

Email*

Enter Email Confirm Email

Phone*

Are you the designated point person of contact for the program?*

Yes

If no, please list the point of contact that will be in communication with CCALAC staff throughout the process.*

Please write name, title, email, and phone number.

Medical assistant externs should be onboarded as volunteers. Will your health center be able to onboard medical assistants by September 30?*

Yes

How many medical assistants can your health center host?*

Are there any special requirements you wish for us to consider?*

Preceptor Information & Clinic Locations

Please provide the contact information of the individual(s) who will be the designated supervisor/preceptor for the program.*

Name

Title

Phone number

Anticipated Health Center Location(s) - Please provide all the location addresses where the program participants will serve.*

Please download the MOA at the top of this application, fill and sign, and upload here.*

Max. file size: 32 MB.

We will provide you a countersigned copy upon review.

Please upload a list of onboarding requirements, volunteer packet, or any other forms that the medical assistant needs to fill out prior to the start of their externship.*

Max. file size: 32 MB.