AHEC Participant Form JS

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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 *

Graduation/Expected Graduation Date *

Emergency Contact *

Emergency Contact Phone *

Are you Hispanic or Latino *

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 *

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

Interior Alaska Area Health Education Center (AHEC) - In Partnership With: Foundation Health Partners, Chief Andrew Isaac Health Center, and the Interior Public Health Partners.