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

Educational Institution

What kind of education or training are you currently in?

Elementary, Middle, or High SchoolCollegeProfessional SchoolResidencyFellowship

Please list the level of education you are currently enrolled in.

(e.g., 8th grade, 11th grade, certificate program, associates degree, bachelors degree, masters degree, doctoral degree, residency, fellowship)

If you are a pre-health student, list your professional interest.(e.g. Pre-Nursing, Pre-Medicine, Pre-Physical Therapy, undecided). If you are a health professions student, list your professional program (e.g. nursing, dental hygiene, medical, occupational therapy, etc.)