Appalachian ROOTS Program Application
Class of 2026
I. DEMOGRAPHICS
High School:
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School County:
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Please Select
Bath
Carter
Elliott
Fleming
Lewis
Menifee
Morgan
Rowan
School Phone:
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Graduation Year:
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First Name:
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MI:
Last Name:
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Address:
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City:
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State:
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Zip Code:
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Home Phone:
Cell Phone:
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Alternate Phone:
Email Address:
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Date of Birth:
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Month
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Day
Year
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Are you a US Citizen?
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Yes
No
Gender:
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Male
Female
Prefer not to say
Other
Race / Ethnicity:
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African-American
Caucasian
Hispanic
Asian or Pacific Islander
Native American or Alaskan
Other
Have you ever been required to leave school for disciplinary reasons?
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Yes
No
If yes, please explain:
Please explain any special circumstances you would like to be known in considering you for the Appalachian ROOTS Program: (e.g. personal learning/physical disability, lengthy family illness, previous AHEC involvement, disabled parent, etc.)
II. HOUSEHOLD / EMERGENCY CONTACT INFORMATION
Emergency Contact:
Name:
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Relationship:
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Phone Number:
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Area Code
Phone Number
Is this person's address different than your address?
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Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
III. STUDENT PROFILE
Extracurricular Activities: List the extracurricular activities in which you have been involved and provide a description of your contribution to that activity. Also please list the calendar year(s) in which you participated in each activity.
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Service (voluntary or paid): List your volunteer or paid work experience. Explain your specific responsibilities and date(s) completed or currently working.
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Honors/Awards: List honors and awards you have received in the past few years (8th - 12th grades). Do not abbreviate award names, for example: National Honor Society - NHS. Also include the grade/year in which you received the honor or award.
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IV. ESSAY
Essays will allow the application review committee to get a better understanding of the student's personality and expectations. Essays will be evaluated on clarity of thought, writing quality, and grammar.
TYPE
and
DOUBLE-SPACE
your writing entry.
Essay (500 words or less) - Why are you choosing Dentistry as your field of interest after high school? What is your future career goal and how would the Appalachian ROOTS program help you in achieving that goal?
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Select File
File must be pdf, doc, docx, jpg, or png format
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VI. TRANSCRIPT
You must provide a transcript of your academic work. You may upload a copy of your most current official high school transcript, or transcripts may also be emailed directly from the school to hannah.little@st-claire.org. Transcripts can also be mailed to: Northeast KY AHEC, Attention: Hannah Little, 316 W. Second St. Suite 203, Morehead, KY 40351.
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Select File
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Name:
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Title:
School:
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Phone:
Email Address:
VIII. STUDENT CONSENT AND AGREEMENT
By signing my digital signature below, I hereby certify that the information provided on this application and attachments I have provided is true and accurate to the best of my knowledge and that the writing entry is my original work. I commit myself to abide by the rules and expectations of the Appalachian ROOTS Program.
Signature
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Day
Year
Date
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