AHEC:
Student Information
First Name:
Last Name:
Present Street Address:
City:
State:
Zip:
Present Phone:
Cell Phone:
Present Email:
Permanent Street Address:
City:
State:
Zip:
Permanent Phone:
Age:
Sex:
Drivers Lic Nbr:
In case of accident or injury, notify:
Name:
Day Phone:
Evening Phone:
Street Address:
City:
State:
Zip:
Relationship:
School and Program Information:
School:
Other:
Degree Sought:
Other:
Year in School:
School Contact:
Phone:
Email:
Preceptor:
Preceptor's Phone:
Course Name:
Other:
Practice/Location Name:
Rotation City:
If city is unknown or not listed, please select 'Other'
and enter the city in this field, if known.
(If you are not participating in the Community Primary Care Rotation Program,
housing is only available in Asheville and Hendersonville.)
Start Date:
(mm/dd/yyyy format) (Sunday before rotation begins)
Departure Date:
(mm/dd/yyyy format) (Last day of rotation)
If you have any impairments or preferences we need to know about, please state them here:
Payment Method:(Rooms are not reserved until the deposit fee is received!)
(AHEC schools are not charged the $50 deposit fee.);
