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
*You will receive confirmation of your application at this email address. This will be the primary email address for contacting you during the application and program process.

Please list 1 other person that will know how to contact you in the future.

Additional Information
Can you answer yes to any of the following?
  • 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 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 doctors and/or other medical providers to serve my community.
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:
Discuss your interest in practicing your profession in a rural or underserved area, including:
Section 5 – Emergency Contact Information
If this person doesn’t live with you:
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

Certification:I hereby certify that:

  • the information given in this application is accurate and complete to the best of my knowledge and belief.
  • I understand that it may be investigated and that any willful false representation is sufficient cause for rejection of this application.
  • I have read and acknowledge the AHEC Scholars program requirements and will comply with all requirements.
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