Western Montana Area Health Education Center

Month

Day

Year

Preferred E-mail Address Currently:

Permanent E-mail (after completing school):

Birth Date (mm/dd/yy):

Ethnicity

Hispanic

Non-Hispanic

Race:

African American/Black

American Indian/Alaska Native

Asian

Native Hawaiian/Pacific Islander

Caucasian/White

Multi-ethnic (more than one)

Primary Phone Number:

Mailing Address while attending school:

Would you consider yourself disadvantaged (using the definition provided)?

Yes

You are (or will be) the first generation in your family to attend college. You have or currently receive Scholarship or Loan for Disadvantaged Students. 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.). While growing up, you lived where there were few medical providers at a convenient distance.

Where did you grow up? (City, State and County)

In what institution are you currently enrolled?

Are you in the institution:

Month

Day

Year

Current education level:

Health Profession Discipline:

Academic Course Coordinator Name:

Academic Course Coordinator Phone:

Month

Day

Year

Month

Day

Year

Rotation Course Code:

Rotation Course Name:

Training Objective/Description:

Training Site/Facility Name:

Training Site/Facility City/Town:

Faculty/Contact Person @ Training Site:

Training Site Contact Phone:

Training Site Contact E-mail:

Housing Provided?

Yes

If yes, housing site name (or NA):

Round trip mileage from home/campus:

Anticipated number of round trips:

I intend/plan/would like to work in a primary care setting:

Yes

Not applicable

I intend/plan/would like to enter a healthcare career as a primary care physician:

Yes

Not applicable

I intend/plan/would like to work with people who are medically underserved:

Yes

Not applicable

I intend/plan/would like to work in a rural area (not city):

Yes

Not applicable

Advisor/School Contact Phone Number:

Please read and check the box below to indicate understanding of the limitations and requirements of AHEC Travel Support. The Western Montana Area Health Education Center (WMT-AHEC) works to improve the supply and distribution of healthcare providers in rural and underserved areas of Montana. As part of this effort, WMT-AHEC may be able to provide travel support for health professions students in rural and underserved clinical rotations. Support is limited both by funding available and the folowing conditions: Participating graduate students must be in their junior or senior year. Rotations must take place at critical access hospitals, rural health clinics, community health centers, or Indian Health Services. Funds are disbursed after the student submits a mileage record upon completion of the rotation, a follow-up survey, and a one-page essay describing his/her experience. Participating students agree to repsond to brief contacts tracking their progress and location of practice.

I understand and agree to the terms listed