Student Conference Application Student Conference Application PART 1: APPLICANT INFORMATIONName(Required) First Last Address(Required) Street Address City State / Province / Region ZIP / Postal Code Email(Required) Phone(Required)Gender(Required) Female Male Non-Binary Class(Required) M1 M2 M3 M4 Race(Required) American Indian or Alaska Native: A person having origins in any of the peoples of North and South America (including Central America), and who maintains tribal afflation or community attachment. Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Black or African American: A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, Marshall Islands or other Pacific Islands. White or Caucasian: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Ethnicity(Required) Hispanic/LatinX: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Non-Hispanic/LatinX PART 2: FAMILY/BACKGROUNDAre you the first generation in your family to attend college?(Required) Yes No Have you previously participated in any UAMS pre-health careers programs? (Example: MASH, CHAMPS, MCAT Prep at ASU, Day in the Life, Pre-Professional Advising)(Required) Yes No If so, please list the program(s).(Required) Have you previously participated in any Regional Campus opportunities? (Example: Rural Student Ambassador, Family Medicine Preceptorship, Service Learning Project, FMIG/RMSLA Officer)(Required) Yes No If so, please list the the opportunity.(Required) Are you a member of RMSLA?(Required) Yes No Are you a member of FMIG?(Required) Yes No PART 3: PRACTICE INTENTHow much do you intend, plan, or want to work in primary care?(Required) Definitely Probably Maybe Probably Not Not At All How much do you intend, plan, or want to work with patients who are medically underserved?(Required) Definitely Probably Maybe Probably Not Not At All How much do you intend, plan, or want to work in a rural area?(Required) Definitely Probably Maybe Probably Not Not At All PART 4: SHORT ANSWERBriefly tell us why you are interested in attending the AAFP National Conference.
