AHEC Primary Care Rural Preceptorship Program (PCRPP) Application

Primary Care Rural Preceptorship Program (PCRPP)

Please complete the form below in its entirety to apply for a spot in the AHEC PCRPP program.
The Primary Care Rural Preceptorship Program (PCRPP) provides Primary Care clinical training experiences for medical students and physician recruitment opportunities in rural and/or medically underserved communities.

Program Goals:
- Introduce the student to primary care in a rural setting
- Provide clinical training in primary care
- Provide students with an understanding of the values and goals of medical practice
- Encourage students to recognize the importance of understanding each patient in relation to his/her family, job and total environment
- Provide the students opportunities to understand the rural physician’s role in the community
- Demonstrate the need for primary care physicians
Timeline:
- Applications due to AHEC PO by Jan. 30, 2026
- Phone/Zoom Interviews: February 2026
- Placements assigned before Spring Break
- Meet/call Preceptor over Spring Break
- Return your Confirmation of Preceptorship form to your sponsoring AHEC office
- Attend the Orientation Workshop – May 2026
- Summer Rotation Dates: June 1-June 30
Applications are due January 30, 2026.
Student Information
Student Name

First NameLast Name
Date of Birth:

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

Other
Student Cell Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Student Email (personal):
example@example.com
Student Email (medical school email):
example@example.com
Home Parish:
Permanent Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Present Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which AHEC programs, if any, have you completed? (Check all that apply):
Student Education and Information
High School Attended:
University Attended:
Degree Earned:
Did you earn an advanced degree? If so, please list below.
Did you have a previous career? If so, please list below.
Biographical Sketch
Father/Guardian Name:

First NameLast Name
Mother/Guardian Name:

First NameLast Name
Tell us a little bit about your family.
Why did you decide on a career in medicine?
Do you have any family members who are in the healthcare field?
Please tell us why you are interested in participating in this AHEC program?
Have you had any previous clinical experience? If so, please specify.
Although this rotation features rural primary care specialties, are there are any other career specialties you are currently considering?
Please note if you have any summer schedule conflicts to allow for coordination of rotation dates.

Please rank your area of interest from 1 (most interested) - 4 (least interested):

Rows	Rank in order of interest (1- most interested, 4- least interested)
Family Medicine
Internal Medicine
OB/GYN
Pediatric

Please list up to 3 preferences in summer location:

Rows	Town/ Parish	Dates: Summer 2026	Will housing be needed? Y / N
First Preference:
Second Preference:
Third Preference:

Signature:
Date

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

Primary Care Rural Preceptorship Program (PCRPP)

Student Information

Student Education and Information

Biographical Sketch