Upstate AHEC Undergraduate Leaders Program

Undergraduate Leaders Program

Interest Inventory
Name *

First Name Last Name
Date of Birth *

Month Day Year Date Picker Icon
Gender *
Race/Ethnicity *

African American Alaska Native American Indian Asian Caucasian Hispanic/Latino Middle Eastern Pacific Islander Prefer Not to Say Other
Primary Language *
Email Address *
example@example.com
Phone Number *
I have participated in a program at AHEC before: *

YES NO
If yes, where: *

Lowcountry AHEC Mid-Carolina AHEC Pee Dee AHEC SC Program Office Upstate AHEC
Undergraduate Institution *
Undergraduate Institution Location *
CIty, State
Classification *
Anticipated Graduation Date *
MM/YY
Major *
Minor
Occupation(s) of Interest *
Please list the health careers that you are currently interested in pursuing.

I understand the steps necessary to transition from Undergrad to Health Professions School or my health career of interest. *

	1	2	3	4	5
I'm not sure what I need to do.						I understand what I need to do.

I have volunteered, shadowed, or interned with a health care organization. *

YES NO
I have earned CPR/First Aid/AED training. *

YES NO
What types of resources and/or support do you feel would be beneficial to you? *

Application Essay Proof-reading Clinical Experience DAT, GRE, MCAT, PCAT study tips Individual Career Planning Interview Tips Mentorship Professional Tips Resume Tips Scholarship & Financial Aid Tips Time Management Tips
Are there any other resources and/or support that we could provide to you that aren't mentioned above? *
I am interested in being ______________ with Upstate AHEC's Health Careers Program. *

an intern a mentor a volunteer none of the above
Would you be interested in completing a brief survey reflecting on your experience? *

Yes No

By signing below, I certify that the information included in this form is true and accurate to the best of my knowledge.

My signature authorizes South Carolina AHEC and the regional AHEC centers (Lowcountry AHEC, Mid-Carolina AHEC, Pee-Dee AHEC, and Upstate AHEC) to release information from this application, as they may deem appropriate. Additionally, I grant South Carolina AHEC and the regional AHEC centers permission to use my personal identifiable information for the purpose of federal, state, or grant related tracking to report programmatic outcomes. I also give my explicit permission for the South Carolina AHEC and the regional AHEC Centers to use my image and statements. Uses include but are not limited to photography, videotape, organizational website, or printed media.
Signature *
Type your Full name.
Date *

Month Day Year
Date Date Picker Icon
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