If you would like to download the form and send it to the Pee Dee AHEC, please click on the link below. If you would like to continue to use the online version of the form, simply fill out the information below.
Click here to download file
Fill the form out completely. Uncompleted forms will be discarded. To move the form, click and hold on the word move in the top right hand corner and drag it where desired.
Applicants must be a current 8th, 9th or 10th grade student.
You will need for this application: 1. Completion of this Form 2. Two letters of reference from a science teacher, math teacher or guidance counselor 3. An official school transcript 4. A one page essay explaining why you are interested in pursuing a career in health
Fields marked with a * are required.
* Your First Name:
Your Middle Name:
* Your Last Name:
Your Maiden Name:
Suffix:
* Your Email:
* Your Mailing Address:
* City:
* State:
* Zip Code:
* County:
Phone Number 1:
Phone Number 2:
* Emergency Number:
* School You Currently Attend:
* Your Current Career Interest:
Your Extra Curricular Activities for this Past Year:
Your Community Service Activities for this Past Year:
* Select one of your reference files to upload:
* Select the second reference file to upload:
* Select your school transcript file to upload:
* Select your one-page essay file to upload:
By submitting this form you authorize the South Carolina AHEC to release information from this application and letters of reference as they may deem appropriate under guidelines of the Freedom of Information Act. It also authorizes the use of my image and statements if selected to participate in the South Carolina AHEC Health Careers Academy. I acknowledge that if selected for program participation, there is a commitment to participate in the activities as outlined and provided on this site for maximum of four consecutive years. It is also acknowledged that the information provided in this application is accurate, and the Selection Committee will exercise judgement in its selection process, and the decision of the selection committee is final. It is also acknowledged that upon submission of this application, you have obtained consent from your parents / guardians.