Student Mentor Application 2023

First Name*

Middle Name

Last Name*

Entry Date (date this form is completed).*

How did you hear about the Health Careers Institute?

At school
Through a friend or family member
Internet Search
SWCAHEC Health Pipelines Associate (Tilton)
Social Media

Best way to communicate with you:*

Phone
Email
Text

Mailing Address Line 1*

Mailing Address Line 2

Mailing City*

Mailing State/Province*

Mailing Zip/Postal Code*

Mailing Country*

Current County/State*

Parent/Guardian Name 1*

First Last

Parent/Guardian 1 mobile phone

Parent/Guardian 1 home phone*

Parent/Guardian 1 work phone

Parent/Guardian Name 2

First Last

Parent/Guardian 2 mobile Phone

Parent/Guardian 2 home Phone

Parent/Guardian 2 work Phone

Other Address Line 1

Other Address Line 2

Other City

Other State/Province

Other Zip/Postal Code

Permanent County/State

Attendee's Mobile Phone Number (Optional)

Attendee's Email (optional)

Other state/county

Parent Email*

Other contact information (optional)

Age at time of attendance*

Gender*

Female
Male
I Identify As

Race (Check one)*

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other

Are you of Hispanic ethnicity?*

Yes
No

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)?*

Yes
No

How would you describe the community in which you grew up?*

Rural (outside of urban areas)
Urban (heavily populated areas)

(all cities and towns in the Southwest region are considered rural).

Are you from a medically under-served area?*

Yes

(All communities in the 8 county SWCAHEC region are considered "medically-underserved areas")

Are you a current student?*

Yes
No

If you are a current student, in what grade will you be in the Fall?*

Name of school you will attend in the Fall of 2022*

If you are interested in a health career, in what field do you want to work?*

Highest level of education completed:*

Middle school
Some high school
High school or GED
Post-high school/ Pre-college

Place of Employment (If not applicable write N/A)

Will you be the first generation in your family to attend college?

Yes
No

Is English your second language?

Yes
No

Do you or your family members participate in a free or reduced lunch program?*

Yes
No

What do you plan to do after high school?

Get a job
Go to a two year college
Go to a four year college or university
Undecided; I need help figuring out my career path

Emergency Contact Information*

First Last

Relationship to attendee*

Phone Number*

Emergency Contact-2

First Last

Relationship to attendee

Phone*

T-shirt and Scrub Sizes (adult sizes)*

Extra Small
Small
Medium
Large
Extra Large

Please note any dietary restrictions

Please note any physical accommodations required

Parent Initials*

By initialing, I indicate my understanding, that upon acceptance into the program, my son/daughter is required to provide a copy of their up-to-date immunization records (including Covid 19 vaccines and boosters) required by Fort Lewis College.

Attendee's Signature*

I certify that the information given in this application is true & correct. I have proofread for accuracy and completeness, for I realize that applications are accepted only when complete.

Parent or Guardian Signature*

By entering name and date above and clicking the "Submit" button below I certify that: 1) I will not hold the Colorado AHEC Program or Southwestern Colorado Area Health Education Center responsible for any accidents that may occur while my son/daughter is participating in the program or at the job shadow site during the Health Careers Institute; 2) I am the custodial parent(s) and/or legal guardian(s) of the person designated as Participant above; and 3) I am over the age of eighteen (18) years of age. 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.

Date*

Phone

This field is for validation purposes and should be left unchanged.

701 Camino Del Rio, Suite 320, Durango CO 81301. Call 970-426-4284.
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SWCAHEC Health Careers Institute Mentor Student Application 2023