HIGH SCHOOL to HEALTH CAREER! Mentor Program 2017-2018

Registration Form

Date: / Activity Title: Van Buren Mentor Program / AHEC Center: Western Region

Information for this form is provided voluntarily. MI-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. Please type or print clearly.

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ALL SECTIONS MUST BE COMPLETED & PRINTED CLEARLY

ACADEMIC LEVEL
☐Year of College (circle one) 1 2 3 4 5
☐ ANTICIPATED DATE OF GRADUATION: (month/year) / / What WMU academic program are you enrolled in?
______
First and Last Name / Birthdate
/ / / Gender
☐M ☐F / Veteran Status
☐Yes ☐No
Ethnicity
(select one)
☐Hispanic
☐Non Hispanic / Race (select one)
☐African American / Black
☐American Indian/Alaskan Native
☐Asian / (Race, continued)
 Native Hawaiian/Other Pacific Islander
☐White
☐More than one Race
College Address / City / State / Zip Code + 4 / County(Not USA)
Hometown Address / City / State / Zip Code / County
Best Daytime Phone # / WMU Email Address
Permanent Email Address / Do you speak Spanish?
☐Yes ☐No
Please answer the following statements:
  • You are (or will be) the first generation in your family to attend college. ☐Yes ☐No
  • You have or currently receive Scholarship or Loan for Disadvantaged Students. ☐Yes ☐No
  • While growing up, you or your family ever used federal or state assistance programs (such as: free or reduced school lunch, subsidized housing, food stamps, Medicaid etc.). ☐Yes ☐No
  • While growing up, you lived where there were few medical providers at a convenient distance. ☐Yes ☐No

Are you from a Rural or Urban area?
☐Rural ☐Urban ☐I’m not sure / Are you from a medically underserved area?
☐Yes ☐No ☐I’m not sure
List two non-related people as contacts:
Name:______Phone Number:______Email:______
Name:______Phone Number:______Email:______
What specific health career are you pursuing?
Where would you like to work? (select one or more)
☐ Small town/rural ☐Big city/urban A medically under-served area ☐I’m not sure
Signing this form acknowledges your interest in participating in this program and provides AHEC permission to contact you periodically to evaluate the effectiveness of AHEC programs as well as hear of your academic and professional achievements and to send communications through the newsletter.
______Signature ______Date

Questions contact

Western Regional Area Health Education Center (WR-AHEC), 200 Ionia SW, Grand Rapids, MI 49503 * 616-771-9487*