AHEC Future Docs Application
Name
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First Name
Last Name
Pronouns
Date of Birth
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-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Mobile Phone
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I consent to receive updates via text message
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Yes
No
School Email
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example@example.com
Personal Email
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example@example.com
Full Mailing Address
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Our federal funder Health Resources and Services Administration (HRSA) asks us to collect gender, race, and ethnicity data. DAHEC recognizes that gender, race, and ethnicity are not meant to fit cleanly into categories, and will continue to advocate for all diversity, equity, and inclusion efforts we are involved in. How to you identify your gender (select one)?
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male
female
transgender or non-binary or another gender
not reported
How do you identify your race (you may select more than one)?
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American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White or Caucasian
How do you identify your ethnicity?
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Hispanic/Latino
Non-Hispanic/Latino
Do you have any military service?
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No military background
Active duty
National Guard
Reservist
Veteran (prior service)
Veteran (retired)
Please check any or all that may apply.
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Previously or currently homeless
Previously or currently in foster care system
Ever received free or reduced lunch
First-Generation college student
Previously or currently eligible for a Federal Pell Grant
Previously or currently receives WIC as parent or child
A parent
Previously or currently receives TANF
Where do you currently attend school (college or university)?
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Current GPA
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Enrollment status
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Full-time
Part-time
Academic Year
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College Junior
College Senior
Declared Major(s)
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Declared Minor(s)
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Anticipated Graduation Date
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-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current College Advisor
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First Name
Last Name
Current College Advisor's Email
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example@example.com
Share why becoming a physician is a good fit for you. What motivates you toward a career in medicine? (Consider including any experiences that led you to this point, mentors, etc.) 200 word max
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What challenges or barriers do you anticipate in pursuing a career as a physician? 200 word max
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Share a story in which you demonstrated either resilience, adaptability or integrity. 200 word max
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Alabama AHEC works to enhance health education and to broaden the distribution of the health workforce particularly for rural and underserved Alabamians. How do you see yourself aligning with our mission for rural and underserved health care? 200 word max
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Extracurricular Activities (List and provide short description of your contribution to that activity and year participated.)
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Service (voluntary or paid): Explain your specific responsibilities and dates completed or currently working
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Honors/Awards received. Only list if you have been elected to an office or for a specific honor. Do not abbreviate names. Include year you received the honor or award.
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What, if any, medical school information sessions have you attended?
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What, if any, MCAT prep courses have you done or other MCAT prep support have you received?
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Upload a copy of your unofficial college transcript
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Program Commitment
• I am aware that the AHEC Future Docs Program requires a commitment to participate.• If I am selected to participate in the Future Docs Program, I commit to completing the requirements of the program (September-March).• If I am selected to the AHEC Future Docs Program, I commit to completing a one-year post-program survey to share my career/education plans going forward.• If I am selected to the AHEC Future Docs Program, I agree to share my MCAT scores. This will be for program information only. MCAT scores are not shared.• Applicants to the Program must be U.S. citizens or hold permanent resident status. Legal residents of Alabama are preferred. Admission to the program will be weighted in favor of applicants residing in or from rural and/or medically underserved areas of Alabama.
Signature
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Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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