FSH HealthCorps Interest Form

Thank you for showing interest in FSH HealthCorps. As an AmeriCorps program, FSH HealthCorps is a way to put your values into action to make a difference where the need is greatest.

Your Contact Information

Your First Name

Your Last Name

Your SSN

Your SSN is needed to ensure non-duplication of accounts.

Your Phone Number

Your Email

Demographics

Your Birthdate

Your Address

Street Address

City

State

Zip Code

KY County

IN County

MI County

AZ County

State of Service

In which state are you interested in completing your HealthCorp service hours?

State

Emergency Contact Information

Emergency contacts should be over the age of 18. If you are currently under the age of 18 we suggest using the information of a parent or guardian

Their First Name

Their Last Name

Their Phone Number

Their Email

Interested Position and Hour Commitment

Identify what program year you are interested in:

Your School:

Please type in the full name of your school

What type of position are you interested in?

How many service hours would you commit to?

CNA License Status

Are you currently enrolled in any of the following Health Science programs or taking Health Science classes?

Which Other Program/Class are you enrolled in?

Do you currently have a nursing certification or are working towards one? Please let us know which (i.e CNA, APN, ADN, RN). This may be the same as you entered into one of the previous questions.

Host Site Questions

To best determine which HealthCorp Host sites may be the best fit for you, based on vaccination requirements at the sites and other criteria, please answer the following questions:

Vaccination Status

If selected the following start dates may be available. Please choose when you are interested in starting the program.

Is there anything else we should know prior to enrolling in the program?