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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
COMP NW
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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