Personal Information

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Name *

Date of Birth *

Email Address *

Phone *

Preferred method of communication *EmailPhone – TalkPhone – Text

Street Address *

City

State/Province

ZIP / Postal Code

Gender *We are required to ask this quesiton per our funding with HRSA. If you do not wish to answer, please enter “N/A” into the textbox.

Race *We are required to ask this quesiton per our funding with HRSA. If you do not wish to answer, please enter “N/A” into the textbox.

Ethnicity *We are required to ask this quesiton per our funding with HRSA. If you do not wish to answer, please enter “N/A” into the textbox.

Are you a Veteran, Reservist, National Guard, or currently serving in one (1) of the eight (8) uniformed services? *YesNo

Would you consider yourself from a disadvantaged background? *YesNoPrefer not to answerHRSA considers someone disadvantaged if any of the following applies to them: a. From a high school with low average SAT/ACT score or below average State test results. b. Person where English is not their primary language. c. First generation college student d. Person from a high school where at least 30 of the enrolled students are eligible for free or reduced priced lunches. e. Anyone below the poverty threshold at https://aspe.hhs.gov/poverty-guidelines

Educational Information

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Name of High School/College/University *

Program of Study

Anticipated Graduation Date *

Current Year of Study *

Other Program/Degrees Completed

For High School Students

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Teacher/Counselor/Advisor Reference

Name

Email Address

Phone

General Program Information

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Placement Site – Please select your primary choice. *

Avera St. Luke’s Hospital (Aberdeen)Avera St. Mary’s Hospital (Pierre)Landmann-Jungman Memorial Hospital Avera (Scotland)Avera Sacred Heart Hospital (Yankton)Platte Medical Center Avera (Platte)Avera Queen of Peace Hospital (Mitchell)

Through October 1 – March 31, facilities require the flu vaccine. With experiences more than 2 hours, facilities require the primary COVID vaccine series. Are you able to meet the vaccination requirements? *YesNoAs these experiences occur in patient-facing facilities, these are as basic requirements enforced by regulatory authorities. Upon acceptance, participants will be required to submit proof of vaccinations.

Your response authorizes the South Dakota Area Health Education Center to share information contained within your application and involvement with the AHEC Program for internal and reporting purposes. By responding to this statement, the facilitators of the AHEC Program are granted the non-exclusive and irrevocable rights and license to make, edit, and use pictures for publicity, news, or advertising, including print, video, broadcast media, and the internet. This material will be utilized for promotional and recruitment purposes. The facilitators of the AHEC Program are released from any and all claims of payment for performance rights, residuals or damages for libel, slander, invasion of privacy, or any claim based on the use of said material. *

Yes, I agree.

 

E-Signature *

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