Associate Program Application and Participant Profile
Fields marked with a red asteriks are required.
*Required
Title
Mr. Ms. Mrs. Dr.
 
First Name*Required
 
Middle Name
 
Last Name*Required
 
E-mail Address
*Required
 
Home Information
  Street Address
City State Zip
Phone
 
Work Information *Required
  Organization
Street Address
City State Zip
Phone *Required
Fax
 
Preferred Address
Home    Work
 

Personal Information

Gender*Required
Male    Female    Prefer Not To Answer
 
Social Security Number (last 4 digits)
XXX - XX - 
 
Date of Birth*Required
 
 
 
Racial/Ethnic Background*
 
If you selected other for your Racial/Ethnic Background, please specify*
 
Do you consider yourself to have ever been from an economically or educationally disadvantaged background?*
Yes    No
 
* Optional; Federal funding guidelines require that these questions be asked of attendees.

Educational Background

Most Advanced Degree *Required
 
Please specify your degree as mentioned above
 
If MD/DO, do you have a CAQ in geriatrics?
No    Yes

Discipline or Profession

Pick the category that best describes your discipline/profession
 
If you selected Other for the above question, please specify

Employment Information


What is your position/job title?  *Required
 
What is your primary role?
 
Which of the following activities do you perform in your current position? (check all that apply)
Continuing Education /Inservice Presentations
Curriculum Development
Teaching Academic Courses
Research Grants
Training and Education Grants
Publications
Serve as a Board/Committee Member
Direct Care Provider
Other, please specify
 
If you selected Other in the question above, please specify

Additional Questions

If you are a health care practitioner and spend at least 50% of your time serving underserved populations (eg., low income/low socioeconomic status, limited access to care, geographically isolated, etc.), please answer the following
 
Site of Practice
(please select if you work in any of the following sites, you can select more than one by holding down the CTRL key)
Community Health Center
Health Care for Homeless Center
Rural Health Clinic
National Health Service Corps Site
Federally-Qualified Health Center
Ambulatory Practice Sites Designated by State Governers
HPSA (Federally Designated Health Professionals Shortage Area)
Migrant Health Center
Public Housing Primary Care Center
Mental Health Center
Indian Health Service
State or Local Health Department
Other, please specify
 
If you checked Other in the above questions, please specify
 
Profile of the Population You Serve
Approximate number of older adults served per month.
What percentage are racial/ethnic minority elders? %
What percentage are disadvantaged/underserved elders (eg. low income/low socioeconomic status, limited access to care, geographically isolated, etc.)? %
What is the largest minority or underserved elderly population you serve (eg. African American, Hispanic, Asian, white, low income/low socioeconomic status, etc.)?