Rural Health Scholars Student Application

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RURAL HEALTH SCHOLARS PROGRAM
Student Application

2023 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 for is open May 1 until June 16, 2023. For more information, visit the Rural Health Scholars Program webpage. Please note that previous Rural Health Scholars Program participants are not eligible.

Thank you for your interest in participating in Well-Ahead Louisiana’s Rural Health Scholars Program. Due to an overwhelming response, the application period for Spring 2023 is now closed. We will open the application period for Year 3 of the program in mid-2023.

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

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, Iberville, Jefferson Davis, Lafourche, Lincoln, Natchitoches, Pointe Coupee, Sabine, St. James, St. Martin, Tangipahoa, Vermilion, Vernon, 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

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)

MD/DO Physicians (Family practice, Internal Medicine, OB/GYN or Pediatrics)

NP: Nurse Practitioner

PA: Physician Assistant

Type of Rotation Needed(Required)

Family Practice/GP

Women’s Health

Pediatrics

Internal Medicine

Behavioral Health

Other

Please list other rotation type(s) needed.(Required)

Post-Graduation Information

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

Yes

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

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

Name one or two parishes you would want to work in.(Required)

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

What motivates you to complete a rotation in a rural 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 have a limited number of providers, and we may not be able to place you in one of your preferred parishes. Are you prepared to go outside of your current location and possibly live somewhere else during your rotation?(Required)

We are limited in the number of students who can participate in this program; what makes you the best candidate?(Required)

Certification

If selected to participate in the Rural Health Scholars Program, I agree to (1) complete a 180-hour (minimum) clinical rotation at the assigned healthcare facility; (2) develop a work plan that is approved by the preceptor at the assigned healthcare facility; (3) participate in an online health equity webinar and submit a certificate of completion; (4) submit an essay detailing my experience providing healthcare services in rural Louisiana; (5) complete a post-rotation survey; (6) turn in a service report showing that all requirements of the program have been met; and (7) create a profile and upload a current CV in 3RNet.

Digital Signature(Required)

First Last

Date(Required)

MM slash DD slash YYYY