NC-Area-L-AHEC
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NC-Area-L-AHEC
YHSC-TIF end usage date-July 24-2023
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High School:
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High School graduation year:
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First Name:
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Middle Name:
Last Name:
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Phone Number (Primary):
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Phone Number (Secondary):
Street Address:
City/Town:
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State:
Zip Code:
Gender:
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Female
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Date of birth:
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Special medical needs/physical limitations/allergies::
The name of the University/College you plan to attend:
University/College Projected Graduation Year:
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2018
2019
2020
2021
2022
2023
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2025
2026
2027
University/College Major:
University/College Minor:
Emergency Contact Name:
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Emergency Contact Relationship:
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Emergency Contact Address:
Emergency contact Phone:
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Mother’s educational background:
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Less than high school diploma
High school diploma
Associate’s Degree (2 yrs.)
Bachelor’s Degree (4 yrs.)
Master’s Degree (>4 yrs.)
Other advanced award
Father’s educational background:
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Less than high school diploma
High school diploma
Associate’s Degree (2 yrs.)
Bachelor’s Degree (4 yrs.)
Master’s Degree (>4 yrs.)
Other advanced award
Racial background:
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American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
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More Than One Race
Are you Hispanic?:
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Yes
No
What languages, other than English, are you fluent in?:
Have you volunteered previously in any AHEC Programs?:
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Yes
No
If yes, please list programs/projects:
Have you ever been a volunteer or provided community service?:
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Yes, in school the year before
Yes, with a youth organization
Yes, with my church
Yes, with my family
Yes, with my neighborhood
No
What activities do you currently participate in?:
Do you have special skills or hobbies?:
State briefly your motivation for applying:
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