Student Interest Form

Students interested in health care professions may enter information to be contacted by their recruiter.

Today's Date

Name(Required)

First Middle Initial Last

Nickname

Last Four of SS#

Race(Required)

Ethnicity(Required)

Date of Birth(Required)

Gender(Required)

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is Permanant Address Same as Current Address?(Required)

Permanant Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

School Email(Required)

Permanant Email(Required)

Hometown(Required)

High School(Required)

Arkansas Region/County(Required)

Select current region based on county.

From Disadvantaged Background?(Required)

Select “YES” if any of the below apply -1st Generation to attend college -From high school with low SAT/ACT Scores or below the average state test results (School’s numbers) -From school district where 50% or less of graduates go to college -Diagnosed physical/mental impairment that substantially limits participation in education experiences – English is not primary language and language is still a barrier to academic performance

Medically Underserved Community?(Required)

There is a shortage of physicians per the number of people in your community

From Rural or Urban Area?(Required)

Underrepresented Minority?(Required)

Current School(Required)

Anticipated Major(Required)

Date Enrolled at Current School(Required)

Expected Graduation Date(Required)

Want More Info?

Student Interest Form

Student Interest Form