Omaha AHEC General Student Information Form

Thank you for your interest in programs supported by the Omaha AHEC. This information is collected as part of the federal grant requirements for the Omaha AHEC.

Your information is kept confidential and your name and personal information is not reported or sold.

If you have questions, please reach out to Clare Maakestad, Omaha AHEC Coordinator at cmaakestad@unomaha.edu.

Demographic Data

First Name

Last Name

School Email Address

Personal Email Address

Date of Birth

Gender

MaleFemaleTransgender, non-binary, or another genderPrefer not to answer

Race

American Indian or Alaska Native
Black or African American
AsianNative Hawaiian or Pacific IslanderWhiteMore than one raceOther

Ethnicity

Hispanic/LatinoNon-Hispanic/Non-Latino

Please list the race(s) you identify with.

Mark all that apply or have applied to you in the past.

First Generation College Student

Eligible for Free & Reduced Lunch

Pell-Grant Eligible
ESL StudentReceive State/Federal AssistanceNone of the above

Home Address

Please list your address growing up. If you had multiple childhood homes, please list the zip code where you spent the most time growing up. If you grew up in another country, list the country and city/town. If you are unsure, simply list your permanent address.

Street Address

City

State

Zip Code

Education Information

This information may be shared with the UNO Pre-Health Professionals Club.

Please list your pre-health interest.

(e.g. Pre-Nursing, Pre-Medicine, Pre-Physical Therapy, undecided)

Please list your major.

(e.g. Biology, Psychology, History)

Anticipated Graduation Year

Newsletter Sign-Up

Would you like to be added to the Omaha AHEC Quarterly Newsletter Mailing List?

YesNo

Contact Information