2024-2025 CI: Healthcare Application

CI: Healthcare is a FREE activity-filled day that offers high school students who have an interest in health careers an opportunity to explore Nursing and Allied Health careers at Franciscan Missionaries of Our Lady University in Baton Rouge, LA or at Louisiana State University - Alexandria in Alexandria, LA.
Interactive activities will be included during each day-long program.

Application Deadline is November 21st. All applicants will be notified after the deadline has passed and all applications have been reviewed by staff. Email notifications will be sent to all students concerning the status of their acceptance. Students that are accepted will be required to confirm their partication via an online link in the acceptance email.

This program is open to students residing in the following parishes: Ascension, Avoyelles, Catahoula, Concordia, East Baton Rouge, East Feliciana, Grant, Iberville, LaSalle, Livingston, Pointe Coupee, St. Helena, Rapides, Vernon, West Baton Rouge, West Feliciana, and Winn.

**Students are responsible for transportation to their designated university.**

Full Name*

First NameMiddle NameLast Name

Last 4 Digits of Student Social Security Number *

Date of Birth*

Date

Gender*

Race / Ethnicity:*

Name of High School Currently Attending:*

Current Grade Level*

Graduation Year*

Current Cumulative GPA*

Must be at least a 2.5

Email Address (DO NOT USE YOUR SCHOOL EMAIL)*

@gmail.com; @yahoo.com; @icloud.com

Mobile Phone Number*

I grant Central Louisiana AHEC the ability to send relevant text messages to the mobile number provided for program application status and other program-related notifications. Message and data rates may apply. Message frequency varies. Reply STOP at any time to unsubscribe from text messages.

Home Phone Number*

Hometown Parish*

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Name*

First NameMiddle NameLast Name

Parent Email*

example@example.com

Phone Number*

Have you applied for this program before?*

YesNo

List up to 3 health careers that you are interested in:*

Have you completed any other Central LA AHEC programs? (Check "None" if you have only applied for other programs.)*

T-Shirt Size:*

Please use the space below to tell us more about yourself in at least 100 words (i.e., why you want to participate, what led you to consider a healthcare career, what makes you a highly qualified candidate, etc.).*

Do you have any medical conditions?*

YesNo

Do you require special assistance in order to participate?*

YesNo

If yes to either question above (medical condition or special assistance), please explain below:

Name of Health Insurance Company*

Please upload a CLEAR photo of your health insurance card.*

Upload a File

pdf, doc, docx, jpg, png, gif

Upload a CLEAR copy of your current/ most recent OFFICIAL high school transcript. (This is obtained from the guidance counselor. Report cards are not accepted. If the document is not clear, the application will be considered incomplete.*

Upload a File

pdf, doc, docx, jpg, png, gif

Upload a CLEAR copy of your LETTER OF RECOMMENDATION from a teacher, counselor, or principal. (If the document is not clear, the application will be considered incomplete.*

Upload a File

pdf, doc, docx, jpg, png, gif

Student Applicant Signature*

Parent Signature*

Today's Date*

Date

Program Participant Application

Student Applicant Information

Your Parent/Guardian's Contact Information

Tell us about yourself

Medical Information

Additional REQUIRED Documents