VAPAA IMPACT Pre-PA Mentorship/Externship Application

VAPAA IMPACT Pre-PA Mentorship/Externship Application

Apply for the VAPAA IMPACT Pre-PA Mentorship/Externship Outreach Program. Please complete all sections to be considered.
Applicant Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Personal Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth (You must be over 18 to participate)*

MonthDayYear
Date
Are you a Veteran?*

YesNo
Military Branch
Dates Served (If applicable)
College or University Attended*
Graduation Date*

MonthDayYear
Date
Type of Degree Earned*
VA Medical Center Location Preference*
Why do you want to become a PA vs an NP or an MD?*
What do you hope to gain from VAPAA IMPACT?*
Are you actively applying for PA school?*

YesNo
If you are not actively applying, what year do you plan to apply?
Are you an Active Pre-PA Member for VAPAA?*

YesNo
Are you an active pre-PA Member for AAPA?*

YesNo
Did you attend the Jan 26, 2026, AAPA webinar?*

YesNo
If you did not attend the webinar, how did you hear about this opportunity?
Applicant's Electronic Signature*

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Date of Signature*

MonthDayYear
Date
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