AAFP National Conference Stipend Application | UAMS Department of Family and Preventive Medicine

PART 1: APPLICANT INFORMATION

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

Gender(Required)

Female

Male

Non-Binary

Race(Required)

American Indian or Alaska Native: A person having origins in any of the peoples of North and South America (including Central America), and who maintains tribal afflation or community attachment.

Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American: A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, Marshall Islands or other Pacific Islands.

White or Caucasian: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Ethnicity(Required)

Hispanic/LatinX: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Non-Hispanic/LatinX

PART 2: FAMILY/BACKGROUND

Are you the first generation in your family to attend college?(Required)

Yes

Have you previously participated in any UAMS pre-health careers programs? (Example: MASH, CHAMPS, MCAT Prep at ASU, Day in the Life, Pre-Professional Advising)(Required)

Yes

If so, please list the program(s).

Have you previously participated in any Regional Campus opportunities? (Example: Rural Student Ambassador, Family Medicine Preceptorship, Service Learning Project, FMIG/RMSLA Officer)(Required)

Yes

If so, please list the program(s).

Are you a member of FMIG?(Required)

Yes

Class(Required)

PART 3: PRACTICE ITENT

How much do you intend, plan, or want to work in primary care?(Required)

How much do you intend, plan, or want to work in a rural area?(Required)

How much do you intend, plan, or want to work with patients who are medically underserved?(Required)