NHSC Ambassadors Administration

New Ambassador Registration
Please provide us with the following information so we can stay in contact with you and provide you with materials and updates on a regular basis. If you have any questions or problems during registration, please contact us at nhscAmbassador@hrsa.gov. Please note that your contact information as an Ambassador will be posted on the NHSC Ambassador Web site at http://nhsc.bhpr.hrsa.gov/ambassadors/2005/Ambassadors.html, so that students, clinicians, and fellow Ambassadors can contact you.
* indicates a required field
Contact Information
*First Name:
*Last Name:
*Credentials:
*Title:
*School/Organization Name:	(Please enter your school or oganization name.)
*School/Organization Select:	(If you are with a school, please select your school from the drop list below in addition to typing the name of your school in the School/Organization field above. If your school is not listed below, please select "School Not Listed". If you are with an organization, please select "With Organization".) State - School - Discipline
HBCU School:	(Check here if you are with an HBCU school.)
*Address:	(Please note that we need a mailing address that accepts overnight mail, so a P.O. box is not appropriate here.)

*City:
*State:
*Zipcode:
*Work Phone/Extension:
Fax:
*Email Address:
*Confirm Email Address:
*Select All Categories That Apply To You (Please select at least one.)
	Admissions Advisor Area Health Education Center (AHEC) Community Health Center Clinician Community Health Center Site Administrator Educator Faculty High School Guidance Counselor High School Principal NHSC Loan Repayor Alumni (completed obligation) NHSC Loan Repayor In Service NHSC Ready Responder NHSC Scholar Alumni (completed obligation) NHSC Scholar In Service NHSC SEARCH Program Director NHSC Site Administrator Practicing Clinician (Non-NHSC) Pre-Health Professions Program Primary Care Associations Primary Care Organizations Residency Director State Office of Rural Health Undergraduate Career Counselor Uniformed Services
*Please select the program that you are affiliated with or select your discipline
	Allopathic Physician Certified Nurse-Midwife Clinical or Counseling Psychologist Clinical Social Worker Dental Hygienist Dentist High School License Master Social Worker (LMSW) Licensed Professional Counselor Marriage and Family Therapist Osteopathic Physician Primary Care Nurse Practitioner Primary Care Physicians Assistant Psychiatric Nurse Specialist Psychiatrist School Social Worker Undergraduate Institution Other - please provide:
Please select the health professions discipline(s) or the program(s) you would like to cover. You may choose to discuss the NHSC with students and clinicians in more than one health professions discipline listed below. Select accordingly.
	Allopathic Physician Certified Nurse-Midwife Clinical or Counseling Psychologist Clinical Social Worker Dental Hygienist Dentist High School License Master Social Worker (LMSW) Licensed Professional Counselor Marriage and Family Therapist Osteopathic Physician Primary Care Nurse Practitioner Primary Care Physicians Assistant Psychiatric Nurse Specialist Psychiatrist School Social Worker Undergraduate Institution
*Select One or More
	Community Affiliated Campus Affiliated Youth Program Affiliated

New Ambassador Registration