West Central Missouri Area Health Education Center
Connecting Students to Careers,
Professionals to Communities, and
Communities to Better Health.

West Central Missouri AHEC (Area Health Education Center)

MAHEC Volunteering Hours Report

MAHEC is required to report general demographic information about participants in the categories below.  This data will be confidentially maintained and will be referenced periodically to evaluate the effectiveness of AHEC services and programs.  We appreciate your cooperation in the completion of this form.  For more information, please contact the West Central Missouri AHEC office at 816-410-8382 or e-mail sbaines@kclinc.org

Please complete the information below and click Report Now.
* indicates required information
 Participant Information
First and Last Names*:
E-mail address*:
Last 4 digits of SS#*:
Date of Birth (MM/DD/YY)*:
Gender*: Male      Female
Ethicity*: American Indian/Alaska Native
Asian
Black/African American
Hispanic/Latino
Native Hawaiian/Other Pacific Islander
White/Caucasian
Multi-Racial
Street*:
City*:
State*:
Zip Code*:
Home Phone:
Area Code and Number:
Cell Phone:
Area Code and Number:
 Education
Name of your current or last school attended*:
Graduation Date (MM/YY)*:
Degree Obtained (Diploma, BSN, MD, etc.):
 Volunteering Information
Name of Location Where You Volunteered*:
Volunteer Location Street Address:
Volunteer Location City*:
Volunteer Location State*:
Volunteer Location Zip Code:
Volunteer Contact Name:
Volunteer Contact Area Code and Telephone:
Dates You Volunteered at this Location *:
Total Hours Volunteered at this Location *:
Briefly Describe Your Volunteer Experience (include your responsibilities, did you enjoy your experience, what you learned from this experience, etc…)*:
Click to Complete Report:

 

Contact Us:

West Central Missouri AHEC
c/o Greater Kansas City LINC
3100 Broadway, Suite 1100
Kansas City, MO 64111

Stephanie Taylor
Executive Director
816-410-8380
816-410-8381 fax
staylor@kclinc.org

Stefanie Baines
Recruitment Coordinator
816-410-8382
816-410-8383 fax
sbaines@kclinc.org

Shaunna Overfelt
Program Assistant
Youth Health Service Corps Coordinator
816-410-8384
soverfelt@kclinc.org

Health Education Coordinator
816-889-8500
staylor@kclinc.org

staff@wcmoahec.org