Rural Scholars Program

Program Application

Please complete the form below in its entirety to apply for a spot in the program.
Eligibility includes:
- Applicant must be from a rural Louisiana town
- Applicant must have a minimum 3.4 cumulative college GPA (copy of college transcript is required)
- Applicant must have a minimum 3.4 cumulative science GPA
- Applicant must have a minimum 24 composite ACT score (copy of ACT score is required)
- Complete all sections in the application including Participation Agreement, Agreement of Photo Release, and Photo of applicant.
Dates for the fall retreat are September 10-11, 2026.

Applications are due to CLAHEC by August 31, 2026. If you have questions or concerns, please reach out to me via email at nicole@clahec.org or phone at 318-443-2855.
Student Applicant Information

It is recommended to start on your application early, and to keep a copy of your answers as these will be similar questions asked by a medical school admissions team.
Student Name

First NameLast Name
Home Parish:
Student Cell Phone Number:
Student Email (not a school email):
Physical Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Gender:
Ethnicity:

Other
Which Central LA AHEC Program have you completed while in high school? (Check all that apply):
College Academic Information
College Name:
College Entry Date and Anticipated Graduation Date:

Entry DateAnticipated Graduation Date
College Major:
College Minor (if applicable):
Current College Clasification:
Current College GPA:
What college Honors courses have you taken? List below:
College Activities/Hobbies and Honors? List below:
High School Academic Information
High School ACT Score:
High School Attended and Graduation Year:

High School NameGraduation Year
Class Rank and High School GPA:

Class RankHigh School GPA
Advanced Placement, DE or CLEP Credit Received:
Please indicate the institution, course, grade received for each course/credit.
Major High School and Community Activities, Honors:
Family Information:
Father/Guardian Name:

First NameLast Name
Father/Guardian's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father/Guardian Occupation:
Father/Guardian Education/College(s):
Father/Guardian Highest Degree:
Mother/Guardian Name:

First NameLast Name
Mother/Guardian's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother/Guardian Occupation:
Mother/Guardian Education/College(s):
Mother/Guardian Highest Degree:
Additional Information
Medical Related Activities (i.e. shadowing, EMT, scribe, volunteering)
Please indicate with asterisks those activities to which you devoted the most time or which you consider most significant. Be sure to list previous AHEC health careers programs.
Describe in your own words the development of your interest in medicine and becoming a physician.
Please Upload an Updated Headshot:

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Below you will find a Participation Agreement PDF. Download the file, fill it out, and submit below.
Below you will find a Agreement of Photo Release PDF. Download the file, fill it out, and submit below.
Participation Agreement and Agreement of Photo Release Upload

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ACT Upload

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College Transcript Upload

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Signature:
Should be Empty:

Program Application

Student Applicant Information

College Academic Information

High School Academic Information

Family Information:

Additional Information