Upstate AHEC Undergraduate Leaders Program

Undergraduate Leaders Program

Interest Inventory
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender*
Race/Ethnicity*

African AmericanAlaska NativeAmerican IndianAsianCaucasianHispanic/LatinoMiddle EasternPacific IslanderPrefer Not to SayOther
Primary Language*
Email Address*
example@example.com
Phone Number *
I have participated in a program at AHEC before:*

YESNO
If yes, where:*

Lowcountry AHECMid-Carolina AHECPee Dee AHECSC Program OfficeUpstate AHECOther
Undergraduate Institution *
Undergraduate Institution Location*
CIty, State
Classification *
Anticipated Graduation Date*
MM/YY
Major*
Minor
Occupation(s) of Interest*
Please list the health careers that you are currently interested in pursuing.

I understand the steps necessary to transition from Undergrad to Health Professions School or my health career of interest. *

	1	2	3	4	5

1 is I'm not sure what I need to do., 5 is I understand what I need to do.

I have volunteered, shadowed, or interned with a health care organization.*

YESNO
I have earned CPR/First Aid/AED training.*

YESNO
What types of resources and/or support do you feel would be beneficial to you?*

Application Essay Proof-readingClinical ExperienceDAT, GRE, MCAT, PCAT study tipsIndividual Career PlanningInterview TipsMentorshipProfessional TipsResume TipsScholarship & Financial Aid TipsTime Management Tips
Are there any other resources and/or support that we could provide to you that aren't mentioned above? *
I am interested in being ______________ with Upstate AHEC's Health Careers Program.*

an interna mentora volunteernone of the above
Would you be interested in completing a brief survey reflecting on your experience?*

YesNo

By signing below, I certify that the information included in this form is true and accurate to the best of my knowledge.

My signature authorizes South Carolina AHEC and the regional AHEC centers (Lowcountry AHEC, Mid-Carolina AHEC, Pee-Dee AHEC, and Upstate AHEC) to release information from this application, as they may deem appropriate. Additionally, I grant South Carolina AHEC and the regional AHEC centers permission to use my personal identifiable information for the purpose of federal, state, or grant related tracking to report programmatic outcomes. I also give my explicit permission for the South Carolina AHEC and the regional AHEC Centers to use my image and statements. Uses include but are not limited to photography, videotape, organizational website, or printed media.
Signature*
Type your Full name.
Date*

MonthDayYear
Date
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