2021 Student Conference Application

PART 1: APPLICANT INFORMATION

Name

First Last

Email

Phone

Ethnicity *

Hispanic or Latino
Not Hispanic or Latino

Race *

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

PART 2: ACADEMIC INFORMATION

In which institution are you currently enrolled? *

ARCOM
NYIT
UAMS

Disipline/Program Enrolled: *

D.O.
M.D.

Anticipated Graduation Date: *

PART 3: FAMILY/BACKGROUND

Are/Were you the first generation in your family to attend college? *

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 *

Yes
No

If so, please list the program(s). *

Have you previously participated in any Regional Campus opportunities? (Example: Rural Student Ambassador, Family Medicine Preceptorship, Service Learning Project, FMIG/RMSLA Officer) *

Yes
No

If so, please list the the opportunity. *

Are you a member of RMSLA? *

Yes
No

Are you a member of FMIG? *

Yes
No

Are you currently enrolled in the AHEC Scholars Program? *

Yes
No

PART 4: PRACTICE INTENT

How much do you intend, plan, or want to work in primary care? *

How much do you intend, plan, or want to work with patients who are medically underserved? *

How much do you intend, plan, or want to work in a rural area? *

SECTION 5: CONFERENCE SELECTION

Please select the conference(s) in which you are applying to attend. *

AAFP National Conference