Bridging Pathways Fall 2-Day Camp Application 2026
October 7 & 8, 2026 ┃10:00 AM - 2:00 PM ┃Morehead, Kentucky
I. DEMOGRAPHICS
High School:
*
School County:
*
Please Select
Bath
Boyd
Carter
Clark
Elliott
Fleming
Greenup
Lawrence
Lewis
Mason
Menifee
Morgan
Montgomery
Nicholas
Powell
Robertson
Rowan
School Phone:
*
Graduation Year:
*
First Name:
*
MI:
Last Name:
*
Address:
*
City:
*
State:
*
Zip Code:
*
Home Phone:
Cell Phone:
*
Alternate Phone:
Email Address:
*
Date of Birth:
*
-
Month
-
Day
Year
Date Picker Icon
Are you a US Citizen?
*
Yes
No
Gender:
*
Male
Female
Prefer not to say
Other
Race / Ethnicity:
*
African-American
Caucasian
Hispanic
Asian or Pacific Islander
Native American or Alaskan
Other
Have you ever been required to leave school for disciplinary reasons?
*
Yes
No
If yes, please explain:
Please explain any special circumstances you would like to be known in considering you for the Bridging Pathways Camp: (e.g. personal learning/physical disability, lengthy family illness, previous AHEC involvement, disabled parent, etc.)
II. HOUSEHOLD / EMERGENCY CONTACT INFORMATION
Emergency Contact:
Name:
*
Relationship:
*
Phone Number:
*
-
Area Code
Phone Number
Is this person's address different than your address?
*
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.
*
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?
*
Select File
File must be pdf, doc, docx, jpg, or png format
Cancel
of
V. 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 Bridging Pathways Fall Camp.
Signature
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Questions?
Contact Kellie Jones, Assistant Center Director at kellie.jones@uky.edu or Tanner Lewis, Health Careers Coordinator at tanner.lewis@uky.edu
Submit
Should be Empty: