"*" indicates required fields EmailThis field is for validation purposes and should be left unchanged.Welcome to the AHEC Scholars Program Application. Completing this form is the first step in a two-step application process. After filling out this form, please click the link at the bottom of the page for the next step in your application, which will be completed on the state AHEC website. Thank you, and good luck!Name* First Last Date of Birth* MM slash DD slash YYYY Cell Phone Number*Email Address* Enter Email Confirm Email At what school are completing your MA program?*Date Certificate Expected*Your graduation date must NOT be in earlier than 2026Date by which your clinical hours must be completed:*Why do you want to participate in the AHEC Scholars Program?*"Please list any languages you speak other than English, along with your level of proficiency for each (e.g., conversational, fluent, or native)."*Do you have a SSN or ITIN?* Yes No Due to stipend disbursements being taxable income, you must have either of these numbers. Can you attend in-person orientation on Friday, July 17 from 9:00am-4:00pm?* Yes No Orientation is MANDATORY for all persons accepted into the program. Not being able to attend makes you ineligible. Site Placements: Are you willing to travel up to 20 miles from your home to complete your clinical hours?*Although we do our best to find a placement in your community, it's not always guaranteed. Upload Your Resume*Accepted file types: pdf, Max. file size: 24 MB. Please submit your resume as a PDFHow did you hear about the AHEC Scholars Program?* Career/Job Fair Clinic/Employee Referral CCALAC Presentation Health Career Connection Idealist Indeed Internet Search Engine Referred by School/Program Unite LA Other Other Signature*CLICK HERE to complete step two of the AHEC Scholars application.
