Pennsylvania Rural Health Association

First Name:

Last Name

University/College Email address:

Personal Email Address

Phone:

Address

City

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ZIP Code

Academic Institution

Major/Minor

Expected Date of Graduation

Why are you interested in becoming a PRHA Student Board of Director Member?

What do you hope to learn and/or gain from serving as a PRHA Student Board of Director Member?

We'd like to know more about you! Please list any relevant credentials and experience that may make you a good fit as a PRHA Student Board of Director Member.

To the Board of Directors, I hereby apply for a position as Student Board of Director Member to serve for a 1-year term. (Typing your name in the field below is the equivalent of your signature)

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Student

(814) 799-0850

Patton, PA 16668

paruralhealthassociation@gmail.com

Pennsylvania Rural Health Association

P.O. Box 24 Patton, PA 16668

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