2024-2025 Healthcare Heroes Expedition Application

Program Participant Application

Please complete the form below in its entirety to apply for a spot in this program.
The "Healthcare Heroes Expedition" program is a FREE activity-filled day that offers high school students who have an interest in health careers an opportunity to explore various areas of healthcare at Louisiana Christian University in Pineville, LA.
Interactive activities will be included during this 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 participation via an online link in the acceptance email.

This program is open to students residing in the following parishes: Avoyelles, Catahoula, Concordia, Grant, LaSalle, Rapides, Vernon, and Winn.

**Students are responsible for transportation to the designated university.**
Student Applicant Information

How can we get in touch with you?
Full Name*

First NameMiddle NameLast Name
Last 4 Digits of Student Social Security Number *
Date of Birth*

MonthDayYear
Date
Gender*
Race / Ethnicity:*

African AmericanAmerican IndianAsianCaucasian (White)HispanicPacific Islander
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*
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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
Your Parent/Guardian's Contact Information

We need to stay in touch with your parent/guardian too.
Parent/Guardian Name*

First NameMiddle NameLast Name
Parent Email*
example@example.com
Phone Number*
Tell us about yourself

What do you want us to know about you?
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.)*

A-HEC of a SummerDASH Into DentistryDay with the DoctorsHealthcare Heroes ExpeditionM.A.S.H.Camp Fast ForwardMedStartFuture Health HeroesNone
T-Shirt Size:*

Adult SmallAdult MediumAdult LargeAdult X-LargeAdult XX-LargeAdult XXX-Large
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.).*

0/0
Medical Information

This is important for us to know in case you are in need of medical treatment while participating in our program.
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.*

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Additional REQUIRED Documents

The following documents are required as part of your completed application. All attachments MUST be CLEAR and LARGE enough to read.
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.*

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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.*

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Student Applicant Signature*

Clear
Parent Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

Program Participant Application

Student Applicant Information

Your Parent/Guardian's Contact Information

Tell us about yourself

Medical Information

Additional REQUIRED Documents