HealthCareers. Discovery Camp. Post Acute Medical Specialty Hospital Corpus Christi, TX June 17 & 18, Application Packet

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1 HealthCareers Discovery Camp Post Acute Medical Specialty Hospital Corpus Christi, TX June 17 & 18, 2015 Application Packet

2 Personal Information Name: Address: City: State: Date of birth: ZIP code: Home phone #: Cell phone #: Gender: Male Female T-Shirt size (adult): XSmall Small Medium Large XLarge XXLarge Please indicate your ethnicity/race below by checking the one that best described you. (Providing this information is voluntary but would be greatly appreciated.) American Indian or Alaskan Native Hispanic or Latino Asian Native Hawaiian or other Pacific Islander Black or African American White More than one race/ethnicity Other Emergency Contact Information Name of father or legal guardian: Daytime phone #: Secondary phone #: Name of mother or legal guardian: Daytime phone #: Secondary phone #: Emergency Contact (if other than individual(s) listed above) Name: Phone #: Relationship: Doctor s Name: Phone #: Known medical conditions, such as allergies, asthma, diabetes or other health or dietary concerns: Medications taken routinely: Special dietary needs: Special accommodations:

3 Educational Information Name of school presently attending: City: What grade level in school will you be entering in the school year? (This year, we will only accept students entering grades 10, 11 or 12.): 10 th 11 th 12 th Have you participated in any of the following experiences? (check all that apply) Attended a health career presentation Attended the TAMHSC Future Health Professionals Conference Belong to a future health careers oriented club (e.g., Health Occupations Students of America, Future Nurses Club) Your Interests Please review the following list and indicate which health-related careers you are considering or would like to know more about. Athletic trainer Dental hygienist Dentist Dietitian or nutritionist Health Educator Laboratory technician or medical technologist Medical science researcher Nurse Occupational health and safety specialist Occupational therapist Paramedic Pharmacist Pharmacy technician Physical therapist Physician or surgeon Physician assistant Radiology technician Respiratory therapist Other:

4 Additional Steps Please have a parent or legal guardian review your completed application and have them sign the Legal Statement enclosed. Please ask two of your current teachers (one science or math and one English or fine arts teacher or a coach) and one counselor to complete the enclosed Educator Reference forms and submit them directly to the camp coordinator by fax, , or , If you have been involved in any medical-related extracurricular activities, you may also have your mentor or sponsor complete and submit a reference form in addition to the above three required. In 300 words or less, please explain why you are interested in this program and what you anticipate getting out of this experience. Include your interest in exploring a health career, your aspirations, and work experience. Add any personal experiences that you feel uniquely qualify you to be selected to be a participant. Please attach your typed essay to your application. All applications MUST be turned in no later than MAY 22 (for mailed applications, post date must be on or before May 22) Mail: ATTN: Becky Smith P.O. Box 2565 Corpus Christi, TX Fax: (361) I have reviewed and verified the above information, and, if selected, I give my child or ward permission to attend the Texas A&M Health Science Center Health Careers Discovery Camp. Parent or legal guardian name (print): Parent of legal guardian signature: Date: Note: If selected, all expenses related to participation in this camp will be covered.

5 Name of student: Educator Reference The above named student is applying for acceptance into the Health Careers Discovery Camp to be sponsored this summer by the Texas A&M Health Science Center. Your input is very important to us, as our space is limited and we hope to select students with the most interest and/or potential in entering a health profession in the future. Specifically, we are looking for students who either have already expressed an interest in pursuing a health-related career or may not have considered it explicitly but who have shown the potential aptitude or related interests. We are also interested in selecting students with a level of maturity and responsibility to benefit most from the experience. All responses will be kept confidential and will be used only for the camp admission process. We greatly appreciate your assistance and input. Print name: Signature: Subject(s) you teach: Attributes Participating in team/ group activities Above Excellent Average Fair Poor Average Respectful of others Potential to succeed in a health-related career Promptness/attendance Leadership ability/ potential Motivation Initiative Reliability Overall recommendation as a potential participant in a health careers camp Any other general comments that would help in our selection:

6 Name of student: Educator Reference The above named student is applying for acceptance into the Health Careers Discovery Camp to be sponsored this summer by the Texas A&M Health Science Center. Your input is very important to us, as our space is limited and we hope to select students with the most interest and/or potential in entering a health profession in the future. Specifically, we are looking for students who either have already expressed an interest in pursuing a health-related career or may not have considered it explicitly but who have shown the potential aptitude or related interests. We are also interested in selecting students with a level of maturity and responsibility to benefit most from the experience. All responses will be kept confidential and will be used only for the camp admission process. We greatly appreciate your assistance and input. Print name: Signature: Subject(s) you teach: Attributes Participating in team/ group activities Above Excellent Average Fair Poor Average Respectful of others Potential to succeed in a health-related career Promptness/attendance Leadership ability/ potential Motivation Initiative Reliability Overall recommendation as a potential participant in a health careers camp Any other general comments that would help in our selection:

7 Name of student: Educator Reference The above named student is applying for acceptance into the Health Careers Discovery Camp to be sponsored this summer by the Texas A&M Health Science Center. Your input is very important to us, as our space is limited and we hope to select students with the most interest and/or potential in entering a health profession in the future. Specifically, we are looking for students who either have already expressed an interest in pursuing a health-related career or may not have considered it explicitly but who have shown the potential aptitude or related interests. We are also interested in selecting students with a level of maturity and responsibility to benefit most from the experience. All responses will be kept confidential and will be used only for the camp admission process. We greatly appreciate your assistance and input. Print name: Signature: Subject(s) you teach: Attributes Participating in team/ group activities Above Excellent Average Fair Poor Average Respectful of others Potential to succeed in a health-related career Promptness/attendance Leadership ability/ potential Motivation Initiative Reliability Overall recommendation as a potential participant in a health careers camp Any other general comments that would help in our selection:

8 Name of student: Mentor Reference (optional) The above named student is applying for acceptance into the Health Careers Discovery Camp to be sponsored this summer by the Texas A&M Health Science Center. Your input is very important to us, as our space is limited and we hope to select students with the most interest and/or potential in entering a health profession in the future. Specifically, we are looking for students who either have already expressed an interest in pursuing a health-related career or may not have considered it explicitly but who have shown the potential aptitude or related interests. We are also interested in selecting students with a level of maturity and responsibility to benefit most from the experience. All responses will be kept confidential and will be used only for the camp admission process. We greatly appreciate your assistance and input. Print name: Signature: How do you know this student? Attributes Participating in team/ group activities Above Excellent Average Fair Poor Average Respectful of others Potential to succeed in a health-related career Promptness/attendance Leadership ability/ potential Motivation Initiative Reliability Overall recommendation as a potential participant in a health careers camp Any other general comments that would help in our selection:

9 Legal Statement Texas A&M University System Health Science Center Minor Model Release I,, being the legal parent/guardian of, hereby give my full permission that the photographs of the above mentioned minor taken by the staff of Texas A&M Health Science Center Marketing and Communications may be used for any purpose, including, but not limited to, exhibition, display, illustration, publication trade and/or advertising. Signature: Name: Minor: Telephone: Address: City: State: Date: I HEREBY WAIVE, RELEASE, DISCHARGE, HOLD HARMLESS, AND PROMISE TO INDEMNIFY AND NOT TO SUE the releasees and all sponsors, organizers and promoting organizations, property owners, law enforcement agencies, public entities, special districts and properties that are in any manner connected with this event, and their respective agents, officials, and employees through or by which the events will be held (the foregoing are also collectively deemed to be releasees) FROM ANY AND ALL RIGHTS AND CLAIMS INCLUDING CLAIMS ARISING FROM THE RELEASEES OWN NEGLIGENCE that I have or which may hereafter accrue to me, and from any and all damages that may be sustained by me directly or indirectly in connection with, or arising out of, my participant in or association with the event, or travel to or return from the camp location. Signature: Name: Date:

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