Area Health Education Center
700 Main Avenue, Suite H
Durango CO 81301
Our Vision & Mission
Board of Directors
College & Higher Ed.
Summer Health Careers Camp
Student Rotation Assessment
Nightingale Luminary And Star Awards 2017
STAR Awards Nomination 2017
Host Home Application
Student Rotation Assessment
Host Home Application
Colorado AHEC Offices
pathways to health
Health Careers Camp Counselor’s Application
SWCAHEC Health Careers Camp - Counselor's Application
By completing and electronically signing the following application, I understand that I will be required to stay at Fort Lewis College, Durango CO from 4:00pm June 13 through June 16 at 4:00pm. I understand my meals and lodging will be provided. Additionally, documentation for time served at camp will be provided upon request.(i.e. credit hours for community service). By checking yes, I have read and understand the above.
Thank you for considering the opportunity to be a counselor for the Health Careers Camp! We are pleased that you would like to help out with the camp. To ensure that the students and counselors are able to share housing accommodations with reasonable expectations, Southwestern Colorado Area Health Education Center (SWC AHEC) requests the following information from the camp counselors. Full formal names, date of birth, and social security number will be needed to conduct a background check. SWC AHEC will cover the costs for the required background checks.*Social Security numbers will be collected after the application is completed and submitted* By checking yes, I have read the above and understand its content.
SWCAHEC receives some funding from the federal government. Because of this, we are REQUIRED to collect demographic information and submit a report bi-annually (no individual-level information is shared and your personal information is kept confidential). This activity is sponsored by a Department of Health and Human Services-Health Resources and Service Administration grant (HRSA.gov) and the information below is required to be collected according to the 3-year approval from the Office of Management & Budget (OMB). For more information please see: http://www.gpo.gov/fdsys/pkg/FR-2013-04-01/pdf/2013-07455.pdf. I have read the above.
(Last Name, First Name, Middle Initial)
Address Line 2
School or Professional Email
Date of Birth
Race (Check all that apply)
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Are you Hispanic?
Are you a current student?
Please indicate your Program of Study (check all that apply):
Middle School student
High School student
Diploma/Certificate program (non-nursing)
Diploma/Certificate program (nursing)
If you are a current student, what is your current academic year?
If you are a current student, in what school are you enrolled? (type N/A if not applicable)
If you are a current student, please state your primary profession (for example: student-NP-women's health)
Highest level of education completed:
Some high school
High school or GED
Post-high school/ Pre-college
Certificate: Two-year community college
Masters Degree (MHA, MSN, MSW, MPH, MSPH)
Post Masters Certificate
Doctorate (PhD, DNP, DNSc, DC, or DPT)
Please state your profession and specialty area, if applicable (for example: Medicine-family practice):
Current Place of Employment (type N/A if not applicable)
How would you describe the community in which you grew up?
Rural (outside of urban areas)
Frontier (sparsley populated areas that are isolated from population centers and services)
Suburban (within or next to heavily populated areas)
Urban (heavily populated areas)
Are you from a disadvantaged background (come from a family with an annual income below a level based on US low income thresholds or come from an area that has inhibited you from obtaining knowledge, skill, and abilities required to enroll in and graduate from a health profession school)?
Are you a veteran?
If you answered "Yes" to the question above, please check ONE of the following
Active Duty Military (in a full-time capacity)
Reservist (in a part-time capacity)
Veteran (Prior Service)
Served less than 90 days
Have you ever been a camp counselor before? If so, where and when?
Please list three (3) References with contact information:
Emergency Contact Name
Emergency Contact Phone
By entering name and date below and clicking the "Submit" button I certify that 1) I understand I will not hold the Colorado AHEC Program or Southwestern Colorado Area Health Education Center responsible for any accidents that may occur while I am volunteering for the program or at the job shadow site during the Health Careers Camp 2) that I am 21 years of age or older 3) that I understand the commitment level necessary 4) that I must request documentation for my time served if needed. This action will constitute an electronic signature in lieu of an actual signature and evidences the parties' mutual intent to enter into a valid and binding contract that will satisfy all applicable legal requirements. This Agreement shall constitute an "original" when printed from electronic files or records established and maintained in the normal course of business.
This field is for validation purposes and should be left unchanged.