Placement Request Application

Placement Request Application

Thank you for your interest in a placement with Waco AHEC and Waco Family Medicine! Please complete the application below to be considered for placement. Submitting this application does not guarantee we will be able to place you, but we will do our best to meet your program requirements.

Name*

Email*

Phone Number*

Date of Birth*

Gender Identity*

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Are you of Hispanic, Latino, or of Spanish origin?*

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How would you describe your race/racial identity?*

Is your hometown considered rural?*

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Emergency Contact*

Emergency Contact Phone*

Placement Type*

What type of placement are you applying for?

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Program of Study*

Current degree you are seeking or department you teach for

Institution*

Texas AHEC East - Waco region requires institutions/universities to be affiliated before we can provide placement. If you are unsure whether your school has an affiliation agreement, please indicate this in the Additional Information section.

Have you been accepted for a placement by a WFM or AHEC Supervisor?*

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Supervisor

If you have already been accepted for an internship or research position by a WFM or AHEC supervisor please include their full name so we can verify placement with them.

GPA*

Graduation Date*

Have you completed hours with us in the past?*

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What semester did you complete hours in the past?

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Have you had rotations with other sites?*

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How many hours have you completed?*

Which semester are you applying for?*

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Please indicate your availability to complete rotations during the week.*

Waco AHEC only places student during Monday-Friday from 8am-5pm. Students are expected to be available for rotations during this time. If you do not have weekday availability, this placement is not a good fit. Please list the days and times you are available so we can determine a clinician match.

Are you vaccinated against COVID-19?*

In order to be eligible for a placement you must be vaccinated against COVID-19.

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Preferred Start Date*

If there is flexibility in your start date, please provide more information in the Additional Information section below.

Preferred End Date*

If there is flexibility in your end date, please provide more information in the Additional Information section below.

Rotation Specialty*

Hour Requirement*

If you have an hour requirement or need for your rotation or internship please indicate it. If no hour requirement needed, please type N/A

Are you Interested in AHEC Scholars?*

The AHEC Scholars Program is for current health professions students interested in gaining additional training and team-based experiences working in rural areas and/or with underserved populations. Students enrolled in AHEC Scholars have priority in the placement process.

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Resume and Headshot*

Please upload a copy of your resume and a professional headshot.

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Additional Information

Please provide an overview of your situation or anything that would be helpful for us while placing you. Our placement program is competitive, so please include any pertinent information.

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