2013 Health Education Scholarship Application Participant Information Question Title 1. Name Last: First: Middle Initial: Question Title 2. Home Address Street: City: Zip: Question Title 3. Select your County Albany Essex Fulton Hamilton Montgomery Rensselaer Saratoga Schenectady Warren Washington Question Title 4. Phone Numbers (xxx-xxx-xxxx) Home Phone: Cell Phone: Question Title 5. Can we text you? Yes No Question Title 6. Email Address: Question Title 7. Birth date (mm/dd/yyyy): Question Title 8. Gender: Male Female Question Title 9. Have you participated in any other Hudson Mohawk AHEC programs in the past? If yes, what program(s)? Question Title 10. What High School/College are you currently attending? Question Title 11. What is your anticipated graduation year? N/A 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 Question Title 12. Have you been accepted into a health career education/training program? If yes, to which program were you accepted? (Include school, major, and/or certification program) Question Title 13. How did you hear about this program? Facebook Website Newspaper Ad Email/Text School Counselor/Teacher Past Participant Classroom Presentation Other (please specify) Next