Kentucky Rural Health Association Student Chapter Application

Kentucky Rural Health Association Student Chapter Application
Personal Information:
Full Name*

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home County
If not from KY, choose other.
If you are not from KY, please list your county and state.
Phone Number

Area CodePhone Number
E-mail
College Information:
College
Name of College/University Attended
Major/Minor
Name of the degree you are pursuing.
City/State
School County
Anticipated Graduation Date
Should be Empty: