American Indians Accessing Health Professions Program Application
Association of American Indian Physicians Western Region Consortium
10th Annual American Indians Accessing Health Professions Program, 2026 CUSM recognizes the terms Native American, American Indian, Alaska Native, as valid and self-determined. This program is open to those 18 years and older. If you have any questions or barriers to submitting, please contact us at Joel.Arvizo-Zavala@cusm.edu
Deadline
Need housing? Deadline is June 3rd. | Don't need housing? Deadline is June 12th. Admitted students will be notified in late June.
Co-Hosted by CUSM & UCR
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Part I. Personal Information | Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender Identity
Male
Female
Transgender
Nonbinary/Genderqueer
For respectful communication, please self-identify
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Academic Email
*
example@example.com
Alternate Email, leave empty if none
example@example.com
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Part I. Personal Information Cont.
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is your Current Addressed the same as your Preferred Mailing Address?
NO
YES
Preferred Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Part II. Accommodations and Dietary Restrictions
ADA: Do you have any accessibility, disability, or support needs we should be aware of?
Do you have any dietary restrictions, allergies, or food preferences we should be aware of?
Vegetarian
Vegan
Gluten Free
Dairy/Lactose Free
Nut Allergy
NA
Other
Will you need housing accommodations during this program
Yes
No
Will you need parking accommodations during this program?
Yes
No
Will you need transportation to the program venue?
Yes
No
Will you need childcare?
Yes
No
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Part III. Family and Tribal Affiliation
Are you a member (or direct descendant of a member) of a FEDERALLY recognized American Indian Tribe or Alaska Native Corporation?
*
Yes
No
If yes, who is the member? (check all that apply)
Self
Mother
Father
Grandmother
Grandfather
Name of the tribe(s) or corporation:
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Part IV. Education Information | College/University
*
Major
*
Minor, if any
School Year
Freshman
Sophomore
Junior
Senior
Graduate
Other, please specify
Cumulative GPA
*
Health Career Goal
*
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List Awards, Honors, or Special Achievements If none, please skip | Name of Award/Honor
Date Received
-
Month
-
Day
Year
Date
Reason
Name of Award/Honor
Date Received
-
Month
-
Day
Year
Date
Reason
Name of Award/Honor
Date Received
-
Month
-
Day
Year
Date
Reason
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Part VI. Programs
Indicate program(s) of interest and program(s) previously participated in, along with the year you participated. NOTE: More information can be found on the AAIP website at: www.aaip.org | *NNAYI 2024 includes college students ages 18-20
Rows
Past Participant
Interested Only
Year(s)
AAIP Annual Meeting & Health Conference
Cross Cultural Medicine Workshop (CCMW)
National Native American Youth Initiative (NNAYI) HIGH SCHOOL STUDENT ONLY
National Native American Youth Initiative (NNAYI) COUNSELOR
College & Medical Student Groups
Financial Aid / Scholarships
National Institutes of Health (NIH) Research Training Opportunities
National Institute of Diabetes & Digestive & Kidney Diseases (NIDDK)
Other program you participated in/are interested in
File Upload | Please submit: *statement, *transcripts, *photo, and *descendancy verification here:
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Recommender’s Email
*
example@example.com
Submit
Should be Empty: