2022 Rural Health Scholars Student Application »Healthcare Access»Louisiana Primary Care Office»Rural Health Scholars Program»Student Application 2022 Rural Health Scholars Student Application Rural Health Scholars Application Thank you for your interest in participating in Well-Ahead Louisiana’s Rural Health Scholars Program. The application period is open until May 31, 2022. For more information, visit the Rural Health Scholars Program webpage. Candidate InformationLegal 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 No Race(Required) White Black Native American Asian Hispanic Prefer Not to Answer Gender(Required) Male Female Prefer Not to Answer Other Besides English, what other languages do you speak? Do you have any prior medical/clinical experience?(Required) Yes No What was your experience?(Required) Example: internships, clinical work, jobs, military, etc.Did you grow up in Louisiana?(Required) Yes No In a rural area (under 25,000 population)?(Required) Yes No Preferred Parishes(Required) Add RemovePlease add your top three rural parishes. We have participating facilities in the following parishes: Allen, Beauregard, Caldwell, Claiborne, DeSoto, Iberia, Jefferson, Lafayette, Lincoln, Livingston, Morehouse, Natchitoches, Orleans, Ouachita, Sabine, St. Helena, St. James, St. Martin, Tangipahoa, Union, Vermillion, Webster. 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 No University InformationUniversity 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) MD/DO Physicians (Family practice, Internal Medicine, OB/GYN or Pediatrics) DDS/DMD: General and Pediatric Dentistry NP: Nurse Practitioner PA: Physician Assistant RDH: Registered Dental Hygienist Post-Graduation InformationDo you currently have a contract for employment post-graduation?(Required) Yes No In what city/state is your contract?(Required) Yes No Do you need assistance with job placement post-graduation?(Required) Yes No N/A Are you willing to seek employment in rural Louisiana?(Required) Yes No 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 No Additional QuestionsDescribe your personal experience and knowledge of rural life.(Required)What motivates you to choose a rural lifestyle and medical practice location?(Required)Describe the pivotal moment in your life when medicine became your primary professional goal.(Required)Citizens in rural areas of Louisiana are facing health disparities. In your own words, describe health disparities.(Required)Citizens in rural areas of Louisiana are facing healthcare inequities. In your own words, describe healthcare inequities.(Required)Based on your personal experience, observations and insights, describe what you believe the roles and responsibilities of a rural practitioner to be.(Required)Have you worked with or shadowed a medical professional in a rural area? If so, what are the rewards and challenges of practicing in a rural area?(Required)List your hobbies and interests.(Required)What personal accomplishment are you most proud of and why?(Required)What is your most significant personal strength?(Required)Why do you feel you would be a suitable candidate for the Louisiana Rural Health Scholars Program?(Required)CertificationIf selected to participate in the Rural Health Scholars Program, I agree to (1) complete the required service time/hours; (2) 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; (3) submit a paper detailing my experience providing healthcare services in rural Louisiana; and (4) participate in a pre- and post-survey.Digital Signature(Required) First Last Date(Required) MM slash DD slash YYYY Δ
