Kentucky HIMA Student Ambassador Application

Kentucky HIMA Student Ambassador Application

Applicant Information

Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal

Employment Information

Are you currently employed?
Employer Address
Employer Address
City
State/Province
Zip/Postal

Education Information

Program Coordinator Name
Program Coordinator Name
First
Last
University Address
University Address
City
State/Province
Zip/Postal

References

List two references, other than family or clergy, along with their contact information.

NOTE: One must be a HIM faculty member in the program which you are currently enrolled.

Reference #1
Reference #1
First
Last
Reference #2
Reference #2
First
Last

Transcript

Please upload a copy of your official or unofficial college transcripts.

Maximum file size: 268.44MB