Student Ambassador Application

Student Ambassador Application Instructions
Letter of Recommendation Form (use this form to upload all recommendations)

Applicant Information

Name *

First

Last *

Last

Phone Number *

Primary Phone

Additional Phone Number

Alternative Phone (optional)

AHIMA Membership Number *

Address *

Current Address/Residence

City *

State

ZIP Code *

Email Address *

Primary Email

Employment Information

Are you currently employed? *

If Yes, Employer

Employer Address

City

State

ZIP Code

Employer Phone

Employer Email

Position

Education Information

College/University *

Major *

Program Coordinator *

First

Last *

Last

Email Address *

Program Coordinator Email

Phone *

Program Coordinator or Department Phone

Anticipated Graduation Date *

Overall GPA *

Address *

City *

State *

ZIP Code *

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.

Name *

First, Last

Email *

Primary Email

Phone *

Primary Phone

Name *

First, Last

Email *

Primary Email

Phone *

Primary Phone

Describe your professional/business experience. *

List any professional association activities that you have been involved with. *

In 1,000 words or less, describe why you're interested in particiapting in the ambassador program. *

Transcript Upload(s) *

Maximum upload size: 134.22MB

Please upload a copy of your official or unofficial college transcripts (PDF Format Only).

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