AHEC Scholars

Section 1 - Personal Data

Please complete the following by filling in the blank, checking the appropriate box, or using the drop-down box:

Applicant Name
Maiden Name & Gender
Ethnicity & Race
Date of Birth
Home Address
Current/Local Address
Contact Info
Additional Information
Section 2 – Academic-Professional Education
Section 3 – Clinical Rotation / Fieldwork / Housing
A portion of the AHEC Scholars program includes opportunities to work with health care providers in rural and underserved areas of Virginia. The following questions will assist the AHEC Scholars team in matching your interests and housing considerations.
Section 4 – Narrative
After reading the AHEC Scholars description, please provide a brief narrative that addresses the following:
Section 5 – Emergency Contact Information
Section 6 – RECOMMENDATION LIST

Please email the separate recommendation form to two (2) recommenders, such as teachers/faculty, community leaders, mentors, coaches, etc. and ask that he or she submit the letter of recommendation directly to VHWDA/Virginia AHEC Program Office at info@vhwda.org

Section 7 – Certification of Application
SIGNATURE

Find Local Support

Blue Ridge Region AHEC – Shenandoah Valley

Capital Region AHEC – Richmond Metro and surrounding areas

Eastern Virginia Region AHEC – Southeast Virginia and Peninsula

Northern Virginia Region AHEC – Northern Virginia

Rappahannock Region AHEC – Northern Neck, Fredericksburg, and Middle Peninsula

South Central Region AHEC – Lynchburg, Danville, and surrounding area

Southside Region AHEC – South of Richmond

Southwest Virginia Region AHEC – Roanoke Valley and West