SEARCH STUDENT APPLICATION

~APPLICATION MUST BE SUBMITTED ELECTRONICALLY

BY Local RHEP or AHEC STAFF ~

APPLICANT: First, Middle, Last, Previous Last Name):

CURRENT ADDRESS:

EMAIL:

CURRENT PHONE NUMBER:

COUNTY OF PERMANENT ADDRESS:

PERMANENT ADDRESS:

(PARENTS OR OTHER RELATIVES IF NECESSARY)

Describe relatives/family ties in rural West Virginia (including location(s))

Are you a NHSC recipient?

If yes, please attach a letter from the NHSC or payment receipt validating status.

CURRENT EDUCATIONAL STATUS:

You must be considered a full time resident or student in good standing with your program.

University/College:

Current year in program or residency:

Field of study:

Area of interest (must be primary care for medical student/residents)

Matriculation date:

Graduation date:

Year of residency completion:

The following information is requested to fulfill our reporting requirements for the Federal agency that funds our project. Completion is voluntary.

Gender: Male Female Date of Birth: ______/_________/_________

Which best describes your racial / ethnic background?

* American Indian or Alaska Native	* Asian (Chinese, Filipino, Japanese, Korean, Asian Indian or Thai) * Asian (from a country other than those listed above) * Native Hawaiian or Other Pacific Islander
* African American/Black * Caucasian/White * Hispanic or Latino
Do you consider yourself to have ever been from an economically or educationally disadvantaged background*? ______ Yes _____ No

*The following criteria may help you to decide whether you are from a “disadvantaged” background: 1) are you in the first generation of your family to go to college? 2) Was your family, to your best knowledge, most likely below the federal poverty level when you were growing up?

EXPERIENCE/GOALS

What are your career goals, including practice location preference(s)?

Why are you interested in rotating with health care professionals at a rural site(s) in West Virginia?

Please describe your work or community service experience within your home community or other rural community. Discuss rural health experience as a health professional or health professions student.

COMMUNITY PROJECT

Please respond to the following with regards to your proposal for a community project at the rural site: (Residents and students must consult with the site coordinator or AHEC Director before completing this section. Your project may involve a role in a new community project, or research project, and/or an ongoing community project at the site.)

SEARCH APPLICANT ESSAY: This portion of the application must read as an essay with an introduction, body and conclusion. For example, if the project includes working with elementary schools, include how many times this presentation will take place, what grade level(s), what teaching aids needed, brochures from organized groups (cancer society, etc.) have been obtained, etc. Most importantly you need to discuss how the project will be evaluated and measured.

The essay must address these points:

· Is your project based on community need?

· Is it an ongoing site project?

· What is the target population?

· What intervention or education do you propose?

· How will the project be evaluated?

Project Title:

Community Project Essay: (1 page minimum—no maximum)

PLEASE ATTACH LETTERS OF RECOMMENDATION, RESUME, ETC, ANY INFORMATION TO SUPPORT YOUR APPLICATION.