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Name (First, MI, Last)
UK Student ID #
Mailing Address (if different from street address)
UK Email Address
Program of Study
Anticipated Graduation Date
Are you currently on academic or disciplinary probation?
May we have permission to verify your GPA?
Why are you interested in serving as a Rural Health Ambassador?
What are your past experience(s) as a leader, mentor, or team member and how will it strengthen your role as an Ambassador?
Describe your public speaking experience, with attention to skills or strengths you think would be helpful in this role.
How can Rural Health Ambassadors promote the image of the UKCERH and build a sense of community on campus?
Please include a brief personal statement describing your understanding of, and commitment to, the challenges facing rural populations with respect to health care, higher education, and improving access to both.
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