AHEC Tracker Area Health Education Centers of Oregon
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Registration Request

Instructions Use this form to register for Pathways to Healthcare Careers 9-12.  The program is conducted at Oregon Pacific AHEC Pathways Virtual Program 20-21  and is scheduled to begin 8/28/2020.  If you have questions about the program you can direct them to the instructor at  jlabahn@samhealth.org.  Fields marked with an asterisk (*) are required.

Student Info *First: *Last: A home phone or mobile phone is required. Home: XXX-XXX-XXXX Mobile: XXX-XXX-XXXX *Email: *Birth Date: *Address: *City: *State: *Zip Code: *County: -Unassigned- Baker Benton Champoeg Clackamas Clatsop Columbia Coos Crook Curry Deschutes Douglas Gilliam Grant Harney Hood River Jackson Jefferson Josephine Klamath Lake Lane Lewis Lincoln Linn Malheur Marion Morrow Multnomah Polk Sherman Tillamook Umatilla Umpqua Union Wallowa Wasco Washington Wheeler Yamhill *Gender: -Unassigned- Female Male *HS Grad Yr: *Bilingual: -Unassigned- No Yes *School: -Unassigned- Academy for Character Education (A.C.E.) Academy of Arts and Academics Adrian Elementary/Middle School Adrian High School Aiken Middle School Al Kennedy Alternative High School Albany Options School Amity High School Armadillo Technical Institute Armand Larive Middle School Ashland High School Astoria High School Baker High School Baker Middle School Bandon High School Bend High School Bend Senior High School Brookings Harbor High School Burns High School Burnt River Charter School Butte Falls Charter School Calvary Christian School Camas Valley Charter School Cascade Christian High School Cascade High School Central Christian School Central High School Central Linn High School Central Middle School Central Oregon Community College Central Oregon Community College Central Point Elementary Chiloquin High School Churchill High School Clara Brownell Cobb School Columbia Gorge Commnity College Condon High School Connections Academy Online Public School Continuing Education Coquille High School Coquille Valley School Corvallis High School Cottage Grove High School Cove Charter School Crater High School Creswell High School Creswell Middle School Crook County High School Crook County High School Crow High School Culver High School Days Creek Charter School Days Creek High School Dayton High School Dayville School Douglas High School Driftwood School Dufur High School Eagle Point High School Eagle Point Middle School Eagle Rock Elementary Early College High School Eastern Oregon University-La Grande Eastern Oregon University-Ontario Echo School Eddyville Community School Elgin High School Elkton Charter School Elkton High School Enterprise High School Fruitdale Elementary Gervais High School Gilchrist Glendale High School Glendale Junior High Glide High School Grant Union High School Grant Union High School Grants Pass High School Haines Elementary Hanford High School Harbor Lights Middle School Harold Woolley Center Harrisburg High School Harvest Christian Academy Heppner High School Hermiston High School Hidden Valley High School Highland Elementary School Hillcrest Elementary Home School Homeschool Hood River Valley High School Howard Elementary School Illinois Valley High School Imbler Charter School Ione High School Irrigon High School Jefferson High School Joseph Charter School Junction City High School Kings Valley Charter School Klamath Union High School Knappa High School La Grande High School La Grande Middle School La Pine High School Lake Oswego High School Lakeview High School Lebanon High School Light House Christian Academy Linfield College Lowell Junior/Senior High School Madras High School Mapleton High School Marist High School Marshall HighSchool Marshfield High School May Roberts Elementary McLoughlin High School McMinnville High School Medford School District MHFA community site Millicoma Intermediate School Milo Adventist Academy Milwuakie High School Mnm Academy Mohawk High School Monroe High School Monument High School Morning Star Christian School Mount Joseph Academy Mountain View High School Myrtle Point High School Network Charter School Newberg High School Newport High School North Bend Middle School North Bend Senior High North Douglas High School North Eugene High School North Lake School North Medford High School North Salem High School North Valley High School Nyssa High School Nyssa Middle School Oak Grove Intermediate School Oakland High School Oakridge High School Ontario High School Ontario Middle School Oregon City High School Oregon Connections Academy Oregon Connections Academy Oregon Health & Sciences University Oregon Institute of Technology Oregon State University Oregon State University Oregon State University-Cascades OSH Museum of Mental Health Pacific High School Parkside Elementary School Pendleton High School Phoenix Charter School Phoenix High School Pilot Rock Pioneer Elementary Pleasant Hill High School Powder Valley School Powers High School Prairie City School Redmond High School Redmond Proficiency Academy Reedsport Community Charter School Resource Link Charter School Riddle High School Ridgeview High School Riverside Jr/Sr High School Rogue River Elementary Rogue River High School Rogue Valley Adventist School Roseburg High School Sams Valley Elementary School Sandstone Middle School Santiam High School SCESD Scio High School Sheldon High School Sheridan Allprep Academy Sheridan High School Siletz Valley High School Sisters High School Siuslaw Middle School South Albany High School South Baker Intermediate South Coast Education Service District South Coast ESD South Eugene High School South Medford HIgh School South Salem High School South Umpqua High School South Wasco High School Southern Oregon ESD Southern Oregon University Southwestern Oregon Community College Spray High School Springfield High School St Marys School St. Paul St. Peter Catholic School Stanfield Secondary School Stayton High School Summit High School Sunridge Middle School Sutherlin High School Sweet Home HIgh School Taft High School Talent Elementary School Talent Middle School The Childrens Farm Home The Dalles Wahtonka High School Thurston High School Tillamook High School Toledo High School Ukiah School Umatilla High School Umpqua Community College Umpqua Valley Christian School Union High School University of Arizona University of Oregon Vale Middle School Virtual Pathways Waldport Wallowa Wallowa Elementary Wallowa High School Warrenton High School Wasco County High School Washington Elementary Weiser Middle School Wellness Business and Sports School West Albany High School West Lane Technical Learning Center Western Oregon University Weston McEwan High School Weston Middle School Wheeler County High School Willamette High School Willamette University Willamina High School Willamina Mid/High School Windy River Elementary Winston Middle School Woodburn High School Woolley Center Yoncalla High School

Career Interest *Career: -Unassigned- Certified Nursing Assistant Chiropractor Clinical Laboratory Dental Assistant Dental Hygienist Dentistry Diagnostic Imaging Dietetics EMT/Paramedic Health Administration Health Information Medical Office Personnel Mental and Social Health Nursing Pharmacy Physical/Occupational Therapy Physician Physician Assistant Veterinarian Vision Care Other Other Career:

Demographics *Ethnicity: -Unassigned- Hispanic Non-Hispanic *Parent1 Education: -Unassigned- Less than HS High School Some College 2Yr College 4Yr College Post Grad *Race: -Unassigned- African American/Black American Indian/Alaskan Native Asian Native Hawaiian/Other Pacific Islander White More than one Race Parent2 Education: -Unassigned- Less than HS High School Some College 2Yr College 4Yr College Post Grad Can you answer yes to any of the following?  -Unassigned- No Yes   - You are (or will be) the first generation in your family to attend college.   - While growing up, you or your family ever used federal or state assistance programs (such as: free or reduced     school lunch, subsidized housing, food stamps, Medicaid etc.).   - While growing up, you lived where there were few medical providers at a convenient distance.   - One or more adult household members is unemployed or furloughed.

Parent Contact Info *Home Lang: -Unassigned- English Other Russian Spanish Vietnamese       First Name Last Name Phone *Parent1: Parent2:   *Emergency Contact:   *Parent1 Email:

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