AHEC of the Plains - AHEC Scholars Online Registration Form
Please fill in the information below to apply for the AHEC of the Plains Scholars program. Your information will solely be used for the course registration and will not be shared with anyone other than the West Texas AHEC administration team.

If you have any question on course registration, please send an email to chris.wiliams@ahecplains.org
Email address *
First Name *
Your answer
Last Name *
Your answer
Gender *
Date of Birth *
Your answer
Student Age Range *
Race *
Ethnicity *
Credential (MD, PhD, etc.)
Your answer
Current Occupation *
Your answer
Address *
Your answer
City *
Your answer
County *
Your answer
State *
Your answer
Zip Code (5 or 9 digits) *
Your answer
Phone Number *
Your answer
How is Permanent Residence Established? *
I am a *
Languages spoken other than English (please list) *
Your answer
Name of institution currently attending *
Your answer
Your Undergraduate Major(s): *
Your answer
Date of Graduation (Expected or Completed) *
Your answer
Your Graduate Degree(s) and Concentration *
Your answer
Do you have any licenses or certifications? if so please list:
Your answer
If selected as a West Texas AHEC Scholar recipient would you agree to longitudinal tracking (up to 3 years after completion)? *
Please list 3 references, with their name, their place of employment, phone number and email address. *
Your answer
List college and high school activities (student government, sports, publications, school-sponsored community service programs, student-faculty committees, arts, music, etc.). List in descending order of significance. You will have space for eight college and four high school activities. *
Your answer
List public service and community activities (homeless services, environmental protection/conservation, advocacy activities, work with religious organizations, etc.). Do not repeat items listed previously. *
Your answer
Describe any further education or training you intend to pursue during or after completion of the AHEC Scholars. *
Your answer
Please tell us about yourself.
Your answer
What do you hope to do and what position do you hope to have five to seven years later? *
Your answer
What do you hope to do and what position do you hope to have upon completing the AHEC Scholars Program? *
Your answer
Training Timeline - by checking each box you agree to the Training Timeline: 40 hours of clinical experience and 40 hours of didactic training per year, a total of 80 hours per year. *
Required
The requirements of the West Texas AHEC Scholar Program are listed below. By checking all of the boxes you agree and understand that the program has been designed to meet the needs of those individuals who desire a challenging curriculum that prepares them for workforce. You are required to maintain a positive attitude and willingness to work and organize your time. You are required to notify your instructor immediately if you fall behind. This statement acts as a commitment to follow through with any/all academic and discipline intervention plan deemed necessary for success. Acceptance into the AHEC Scholars Program is an invitation to work hard, to excel in all that you do, and to reach your full potential in every regard. By checking all of the boxes below you are stating you understand and agree to following requirements. *
Required
I have read and understand the conditions of the AHEC Scholars Program as explained above. I affirm that I plan to utilize the training provided to pursue or enhance my educational experience and my career. I understand that this application will be available only to qualified people who need access to it in the course of their duties. If selected as a AHEC Scholar, I agree to the terms and conditions. I affirm the information contained herein is true and accurate to the best of my knowledge and belief. By checking yes below I agree to the terms. *
Thank you for completing the registration form. You will be contacted by your local West Texas AHEC office for further instructions.
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy