Student Application

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Student Application

Rural Health Dental Scholars Program
Student Application

2023 Rural Health Dental Scholars Student Application

Rural Health Dental Scholars Application

Thank you for your interest in participating in Well-Ahead Louisiana’s Rural Health Dental Scholars Program. The application period for 2023 is now open until XXX, XX 2023. For more information, visit the Rural Health Dental Scholars Program webpage.

Candidate Information

Legal Name(Required)

Preferred Name (if different from Legal Name)

Email(Required)

Phone(Required)

Home Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Mailing Address (if different from Home Address)

Street Address City State / Province / Region ZIP / Postal Code

Date of Birth(Required)

MM slash DD slash YYYY

Social Security Number or TIN(Required)

City and State of Birth(Required)

Are you a U.S. citizen/national?(Required)

Yes

Race(Required)

White

Black

Native American

Asian

Hispanic

Prefer Not to Answer

Other

Gender(Required)

Male

Female

Prefer Not to Answer

Other

Did you grow up in Louisiana?(Required)

Yes

In a rural area (under 25,000 population)?(Required)

Yes

Preferred Parishes(Required)

Please add your top three rural parishes. We have participating facilities in the following parishes: Acadia, Allen, Ascension, Assumption, Avoyelles, Beauregard, Bienville, Evangeline, Grant, Iberia, Iberville, Jefferson, Lafayette, Lafourche, Lincoln, Livingston, Morehouse, Natchitoches, Orleans, Ouachita, Pointe Coupee, Rapides, Sabine, St. Helena, St. James, St. John the Baptist, St. Landry, St. Martin, Tangipahoa, Union, Vermilion, Vernon, Washington, Webster, Winn. We will do our best to match you with a facility in your top three parishes. Assignments will depend on facility availability in the desired parishes and the type of healthcare provider needed at the facility.

Your Initials(Required)

Enter your initials to acknowledge that you understand that you may not be placed in a parish listed above.

Will you need assistance in obtaining lodging?(Required)

Yes

University Information

University Name(Required)

University Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Expected Graduation Date(Required)

MM slash DD slash YYYY

Program Name(Required)

Program Director/Dean Name(Required)

Program Director/Dean Email(Required)

Main Phone(Required)

Health Professional Type(Required)

DDS/DMD: General and Pediatric Dentistry

RDH: Registered Dental Hygienist

Type of Rotation Needed(Required)

Family Practice/GP

Women's Health

Pediatrics

Internal Medicine

Other

Please list other rotation type(s) needed.

Post-Graduation Information

Do you currently have a contract for employment post-graduation?(Required)

Yes

In what city/state is your contract?(Required)

Yes

Do you need assistance with job placement post-graduation?(Required)

Yes

N/A

Are you willing to seek employment in rural Louisiana?(Required)

Yes

N/A

Well-Ahead Louisiana support programs that assist with student loan repayment. Are you interested in applying for these programs? (Conditions apply)(Required)

Yes

Additional Questions

Describe your personal experience and knowledge of rural life.(Required)

What motivates you to choose a rural lifestyle and medical practice location?(Required)

How would you say health disparities and healthcare inequities affect our rural residents?(Required)

What non-academic, personal accomplishment are you most proud of and why?(Required)

We are limited in the number of students who can participate in this program; why should you be one of the students selected?(Required)

Certification

If selected to participate in the Rural Health Dental Scholars Program, I agree to (1) complete the required service time/hours; (3) participate in a 2-hour seminar that will detail health disparities, discuss health equity and provide information on chronic disease prevention efforts in rural Louisiana; (4) submit a paper detailing my experience providing healthcare services in rural Louisiana; (5) participate in a pre- and post-rotation survey.

Digital Signature(Required)

First Last

Date(Required)

MM slash DD slash YYYY