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HOSA
FHP Student Services/Alaska AHEC Program Participant Form
*In order for us to provide grant-funded programs, we are required to ask certain information from all participants. Your personal information will be handled with complete confidentiality and not shared outside of the AHEC organization or Foundation Health Partner: TVC/FMH/DC.
*
Indicates required field
Name
*
First
Last
Date of Birth
*
Gender
*
Birthplace or Childhood Residence
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Email
*
Phone Number
*
High School Attending/Attended
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Graduation/Expected Graduation Date
*
Emergency Contact
*
Emergency Contact Phone
*
Are you Hispanic or Latino
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Yes
No
What is Your Race? Choose All that Apply
*
White
Black or African American
Asian American
Native Hawaiin or Other Pacific Islander
American Indian
Alaska Native
Other
U.S. Citizen
*
Yes
No
Can you answer yes to either one of these statements?
-I am the first generation in my family to attend college.
-I attend(ed) a small rural high school.
Choose One
*
Yes
No
Can you answer yes to either one of these statements?
-I had or currently receive a scholarship or loan for disadvantaged students.
-While growing up, I or my family used federal or state assistance programs (such as: free or reduced school lunch, WIC, food stamps, medicade, subsidized housing, etc.
Choose One
*
Yes
No
Submit
