AHEC Scholars Application

Program Application

Please complete the form below in it's entirety to apply for a spot in this program.
The AHEC Scholars program is designed to give currently enrolled health professions students additional training and team-based clinical experiences with health care providers in rural and underserved areas.

Students selected to participate in this 2 year training program will develop high-quality, job readiness, health care skills through intense inter-professional collaborations with various health care disciplines.

Additional benefits include:
- Hands-on experience working with medically trained health professionals from diverse backgrounds
- Earn an additional 40 hours of didactic training and 40 hours of clinical training above required health professions curricula
- Expanded knowledge about rural and community-based care while working with underserved populations
- Open to all disciplines that support primary health care services delivery
Requirements for Participation
- Completed application
- Must have transportation—this program includes training workshops at various rural sites (60 mile radius)
- Be a full-time nursing student at LSUA / full-time medical student at LSU Health Shrveport, School of Medicine
- Must be willing to sign a 2 year program participant commitment agreement
Application Deadline is September 8th. 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.
Student Applicant Information

How can we get in touch with you?
Full Name

First NameMiddle NameLast NameSuffix
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Race / Ethnicity:
Are you a United States veteran?
Mobile Phone Number
Format: (000) 000-0000.
Personal Email Address (DO NOT USE YOUR SCHOOL EMAIL)
@gmail.com; @yahoo.com; @icloud.com
School Email Address (must be different than you personal)
@lsua.edu, @lsuhs.edu
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
Home Parish
School Information:
Name of College/University/Medical School Currently Attending:
Current Year of Study
Graduation Year
Current Cumulative GPA
Must be at least a 3.0
Have you completed any other Central LA AHEC programs?
T-Shirt Size:
Please use the space below to tell us about any college activities/honors/clubs that you are involved in:
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?
Do you require special assistance in order to participate?
If yes to either question above (medical condition or special assistance), please explain below:
Are you currently taking any medication?
If yes, please list all medications below:
Name of Health Insurance Company:
Policy / Group Number:
Please upload a CLEAR photo of the FRONT of your health insurance card.

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Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
Program Participant Agreement
In case of an accident or serious illness, I hereby authorize hospital officials to make whatever arrangements necessary and to contact me immediately. I understand that it remains my responsibility to make any future information changes on this medical form as the need arises, by contacting Central Louisiana AHEC. Otherwise, this authorization will remain in effect, as of this date, until program completion. Neither Central Louisiana Area Health Education Center, LSU Alexandria, LSU Health Shreveport, nor University Health Shreveport assumes responsibility for any medical charges.
Student Applicant Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Program Application

Student Applicant Information

School Information:

Medical Information

Program Participant Agreement