Program Participant Application
Please complete the form below in it's entirety to apply for a spot in this program.
Student Applicant Information
How can we get in touch with you?
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Female
Male
Race / Ethnicity:
*
African American
American Indian
Asian
Caucasian (White)
Hispanic
Pacific Islander
Name of High School Currently Attending:
*
Current Grade Level
*
Please Select
Senior
Graduation Year
*
Please Select
2026
Current Cumulative GPA
*
Must be at least a 3.0
Email Address (DO NOT USE YOUR SCHOOL EMAIL)
*
@gmail.com; @yahoo.com; @icloud.com
Mobile Phone Number
*
I grant Central Louisiana AHEC the ability to send relevant text messages to the mobile number provided for program application status and other program-related notifications. Message and data rates may apply. Message frequency varies. Reply STOP at any time to unsubscribe from text messages.
Home Phone Number
*
Hometown Parish
*
Please Select
Ascension
Avoyelles
Catahoula
Concordia
East Baton Rouge
East Feliciana
Grant
Iberville
LaSalle
Livingston
Pointe Coupee
Rapides
St. Helena
Vernon
West Baton Rouge
West Feliciana
Winn
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Parent/Guardian's Contact Information
We need to stay in touch with your parent/guardian too.
Parent/Guardian Name
*
First Name
Middle Name
Last Name
Parent Email
*
example@example.com
Phone Number
*
Tell us about yourself
What do you want us to know about you?
Have you applied for this program before?
*
Yes
No
How did you hear about the AHEC program?
AHEC Ambassador at your school
AHEC Flyer/Poster at your school
AHEC Representative/Presentation at your school
Previous Participant
School Guidance Counselor
Social Media
List up to 3 health careers that you are interested in:
*
Which healthcare professional(s) are you most interested in shadowing?
Physician
Physician Assistant
Nurse Practitioner
Which Central LA AHEC programs have you completed?
*
A-HEC of a Summer
CI:Healthcare
DASH Into Dentistry
Day with the Doctors
Camp Fast Forward
Healthcare Heroes Expedition
Future Health Heroes
MedStart
None
T-Shirt Size:
*
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult XX-Large
Adult XXX-Large
Scrub Pants Size (Sizes are Unisex):
*
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult XX-Large
Adult XXX-Large
Please use the space below to tell us more about yourself in at least 100 words (i.e., why you want to participate, what led you to consider a healthcare career, what makes you a highly qualified candidate, etc.).
*
Medical Information
This is important for us to know in case you are in need of medical treatment while participating in our program.
Do you have any medical conditions?
*
Yes
No
Do you require special assistance in order to participate?
*
Yes
No
If yes to either question above (medical condition or special assistance), please explain below:
Name of Health Insurance Company
*
Please upload a CLEAR photo of your health insurance card.
*
Upload a File
Drag and drop files here
Choose a file
pdf, doc, docx, jpg, png, gif
Cancel
of
Additional REQUIRED Documents
The following documents are required as part of your completed application. All attachments MUST be CLEAR and LARGE enough to read.
Upload a CLEAR copy of your current/ most recent OFFICIAL high school transcript. (This is obtained from the guidance counselor. Report cards are not accepted. If the document is not clear, the application will be considered incomplete.
*
Upload a File
Drag and drop files here
Choose a file
pdf, doc, docx, jpg, png, gif
Cancel
of
Upload a CLEAR copy of your current/ most recent ACT score.
*
Upload a File
Drag and drop files here
Choose a file
pdf, doc, docx, jpg, png, gif
Cancel
of
Upload a CLEAR copy of your LETTER OF RECOMMENDATION from a teacher, counselor, or principal. (If the document is not clear, the application will be considered incomplete.
Upload a File
Drag and drop files here
Choose a file
pdf, doc, docx, jpg, png, gif
Cancel
of
Student Applicant Signature
*
Parent Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: