2017 NHSC Corps Community Month - Wayne State University

Thank you for your interest in the 2017 NHSC Corps Community Month. Please register for the event by providing the information below. Note: Some events are scheduled to take place on different dates to accommodate the different schedules of students, departments or universities. Please note the dates and time when selecting your site.

Fields with asterisks (*) are required.

First name *

Last name *

Email *

Address line 1 *

Address line 2

City *

State/province/region *

Postal/zip code *

Country *

Primary Phone Number *

Date of Birth *

Gender *

Ethnicity *

Race *

Veteran Status *

College/University *

Site Selection *

February 22, 2017--10 a.m.-11 a.m.: Wayne State University|PA Students|Eugene Applebaum College of Pharmacy And Health Sciences, 259 Mack Ave. Suite 2590, Detroit, MI 48201

If you are employed, indicate the type of setting in which you work (check all that apply)

If you select "other" for your work setting, please specify/explain: otherwise, type NA

If you selected "Allied Health" or "Other" for your health discipline, please specify if you did not choose either of these options, type NA

Current Education Level *

If you selected "other" for your education level, please specify/explain, otherwise type NA*

Check all of the statements that apply

You are the first generation in your family to attend college

You have received a scholarship or loan for disadvantaged students

While growing up, you or your family used a federal or state assistance program (e.g., free/reduced school lunch/ subsidized housing, food stamps, Medicaid, etc.)

While growing up, you lived where there were few health care providers within a convenient distance

None of these statements are applicable

Which setting describes where you grew up? *

Have you ever heard of the NHSC Loan Repayment Program?

Yes

Have you ever heard of the Michigan State Loan Repayment Program?

Yes

May we contact you after graduation to see if you applied to the NHSC Loan Repayment Program?

Yes

What is the date of your anticipated graduation?