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
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
KY County
Please select...
Adair
Allen
Anderson
Ballard
Barren
Bath
Bell
Boone
Bourbon
Boyd
Boyle
Bracken
Breathitt
Breckinridge
Bullitt
Butler
Caldwell
Calloway
Campbell
Carlisle
Carroll
Carter
Casey
Christian
Clark
Clay
Clinton
Crittenden
Cumberland
Daviess
Edmonson
Elliott
Estill
Fayette
Fleming
Floyd
Franklin
Fulton
Gallatin
Garrard
Grant
Graves
Grayson
Green
Greenup
Hancock
Hardin
Harlan
Harrison
Hart
Henderson
Henry
Hickman
Hopkins
Jackson
Jefferson
Jessamine
Johnson
Kenton
Knott
Knox
Larue
Laurel
Lawrence
Lee
Leslie
Letcher
Lewis
Lincoln
Livingston
Logan
Lyon
Madison
Magoffin
Marion
Marshall
Martin
Mason
McCracken
McCreary
McLean
Meade
Menifee
Mercer
Metcalfe
Monroe
Montgomery
Morgan
Muhlenberg
Nelson
Nicholas
Ohio
Oldham
Owen
Owsley
Pendleton
Perry
Pike
Powell
Pulaski
Robertson
Rockcastle
Rowan
Russell
Scott
Shelby
Simpson
Spencer
Taylor
Todd
Trigg
Trimble
Union
Warren
Washington
Wayne
Webster
Whitley
Wolfe
Woodford
Emergency Parent Contact Information
Their First Name
Their Last Name
Their Phone Number
Their Email
Interested Position and Hour Commitment
Identify what program year you are interested in:
Please select...
24-25
25-26
Your School:
Please type in the full name of your school
What type of position are you interested in?
Please select...
Direct Service Professional
Nutrition Specialist
Patient Experience Representative
Maintenance Assistance
Business & Communications Professional
How many service hours would you commit to?
Please select...
300
450
675
900
1200
CNA License Status
Please select...
I currently hold a CNA/SRNA/MNA License
I am currently enrolled and completing a CNA/SRNA/MNA Course
I have not started a CNA/SRNA/MNA Course
Are you currently enrolled in any of the following Health Science programs or taking Health Science classes?
Please select...
EKG
Phlebotomy
Medical Nurse Aide, Certified Nursing Assistant
Dietary Aide
Nursing
Social Services
Other
No, I am not in a Health Science program or taking any related 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
Please select...
I am fully vaccinated against Covid-19
I am not fully vaccinated against Covid-19
If selected the following start dates may be available. Please choose when you are interested in starting the program.
Please select...
August 20, 2024
October 8, 2024
December 3, 2024
February 11, 2025
April 8, 2025
Is there anything else we should know prior to enrolling in the program?
Other Question
How did you hear about FSH HealthCorps?
Eligibility Verification
Please attach a photo of your Drivers License or other Government Issued ID showing your name. This is important so that we can see your full name, as it is on record with the government, and verify your residency to ensure your eligibility.
Drivers License or Government Issued ID
Contact Information