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Western Montana Area Health Education Center
UM
Western Montana Area Health Education Center
Career Support
Rural Clinical Rotations Travel Awards
Student Application for Clinical Rotation Travel Support
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Career Support
UM Pre-Med
Rural Clinical Rotations Travel Awards
WWAMI Missoula
Jobs in Montana
Health Professions Programs
MHA Academy
Today's Date:
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Name:
*
Preferred E-mail Address Currently:
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Permanent E-mail (after completing school):
*
UM/MSU ID Number:
*
Birth Date (mm/dd/yy):
*
Age:
*
Gender:
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Male
Female
Ethnicity
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Hispanic
Non-Hispanic
Race:
*
African American/Black
American Indian/Alaska Native
Asian
Native Hawaiian/Pacific Islander
Caucasian/White
Multi-ethnic (more than one)
Primary Phone Number:
*
Mailing Address while attending school:
*
Would you consider yourself disadvantaged (using the definition provided)?
*
Yes
No
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 ever 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 medical providers at a convenient distance.
Where did you grow up? (City, State and County)
*
In what institution are you currently enrolled?
*
Are you in the institution:
*
-- Make a selection --
Full-time
Part-time
Anticipated graduation date:
*
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Current education level:
*
-- Make a selection --
Certificate
Two-year College/Community College
Associates
Diploma (nursing)
Four-year College
Bachelor's
Twelve-month post-baccalaureate
Pre-matriculation/pre-graduate school
Masters (MHA, MS, MSN, MSW, MPH, MSPH)
Post-Masters Certificate
Doctorate (PhD, DNP, DNSc, DC, DPT)
Post-Doctorate
Resident
Fellow
Faculty Member
Post Graduate
Medicine Doctor (MD)
Doctor of Osteopathy (DO)
Doctor of Dental Surgery (DDS, DMD)
Doctor of Pharmacy (PharmD)
Doctor of Veterinary Medicine (DVM, VMD)
Doctor of Psychology (PsyD)
Doctor of Public Health (DrPH)
Doctor of Science (ScD)
Adult Learner
Displaced Worker
Other
Health Profession Discipline:
*
-- Make a selection --
Allopathic Medicine
Chiropractic
Osteopathic General Practice
Optometry
Pharmacy
Podiatry
Psychiatry
Veterinary Medicine
Physician Assistant
Licensed Practical Nurse
Nurse Midwife
Nurse Practitioner
Registered Nurse
Dental Assistant
Dental Hygiene
General Dentistry
Nutrition Dietetics
Clinical Psychology
Clinical Social Worker
Substance Abuse/Addiction Counselor
Community Health Worker
Health Education/Behavior
Health Services/Hospital Administration
Public Health
Clinical Lab Worker
EMT/Paramedics
Health Information Systems
Occuptaional Therapy
Physical Therapy
Other
Academic Course Coordinator Name:
*
Academic Course Coordinator Phone:
*
Rotation Course Start Date:
*
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Rotation Course End Date:
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Total Hours:
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Rotation Course Code:
*
Rotation Course Name:
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Training Objective/Description:
*
Training Site/Facility Name:
*
Training Site/Facility City/Town:
*
Faculty/Contact Person @ Training Site:
*
Training Site Contact Phone:
*
Training Site Contact E-mail:
*
Housing Provided?
*
Yes
No
If yes, housing site name (or NA):
*
Round trip mileage from home/campus:
*
Anticipated number of round trips:
*
I intend/plan/would like to work in a primary care setting:
*
Yes
No
Not applicable
I intend/plan/would like to enter a healthcare career as a primary care physician:
*
Yes
No
Not applicable
I intend/plan/would like to work with people who are medically underserved:
*
Yes
No
Not applicable
I intend/plan/would like to work in a rural area (not city):
*
Yes
No
Not applicable
Advisor/School Contact Phone Number:
*
Please read and check the box below to indicate understanding of the limitations and requirements of AHEC Travel Support. The Western Montana Area Health Education Center (WMT-AHEC) works to improve the supply and distribution of healthcare providers in rural and underserved areas of Montana. As part of this effort, WMT-AHEC may be able to provide travel support for health professions students in rural and underserved clinical rotations. Support is limited both by funding available and the folowing conditions: Participating graduate students must be in their junior or senior year. Rotations must take place at critical access hospitals, rural health clinics, community health centers, or Indian Health Services. Funds are disbursed after the student submits a mileage record upon completion of the rotation, a follow-up survey, and a one-page essay describing his/her experience. Participating students agree to repsond to brief contacts tracking their progress and location of practice.
*
I understand and agree to the terms listed
* indicates a required field
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