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Student Resident Form for Community Rotation

Information for this form is provided voluntarily. AHEC is required to report information about program participants. Data will be kept private to the extent allowed by law and will be referenced periodically to evaluate the effectiveness of AHEC services and programs. We appreciate your cooperation in the completion of this form

Registration for community rotations.
  • Middle Initial
  • Credentials such as MD, PhD etc.

  • Primary telephone number
  • List your mobile phone number

  • Press and hold Ctrl to select more than one option.
    You are (or will be) the first generation in your family to attend college.

    You have or currently do receive Scholarships or Loans for Disadvantaged Students.
    While growing up, you or your family used federal or state assistance programs (such as: free or reduced school lunch, subsidized housing, food stamps, Medicaid etc.)

    While growing up, you lived where there were few medical providers at a convenient distance.

  • City and State of hometown at time of high school graduation

    Education level already achieved. Select all that apply
  • List other language 1

  • List other language 2

  • Discipline (Select all that apply)

  • Specialty (Select all that apply)

    Identify your specialty (you may select all that apply)

  • Enter the (4 digit) year when you expect to graduate.

    See Regional Map:
  • Enter an alternate Email address
  • This field is for validation purposes and should be left unchanged.