2013 Health Careers Summer Camp Application Checklist

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1 2013 Health Careers Summer Camp Application Checklist Please use this checklist to confirm that all required documents have been obtained and completed before mailing your complete application packet to Big Bend AHEC Application Form completed Signature Authorization Form signed by student and parent or guardian Sealed High School Transcript Teacher #1 Completed Evaluation Form (in sealed envelope with teacher s signature across the sealed tab) Teacher #2 Completed Evaluation Form (in sealed envelope with teacher s signature across the sealed tab) One-Page Essay (typewritten, no more than 250 words) Current Photograph of student (head shot facing camera) Include T-Shirt Size Application deadline is Friday, April 26, 2013 Please mail your application to: Attn: Angelika Parker Big Bend AHEC 325 John Knox Road, Building M, Suite 200 Tallahassee, FL 32303

2 Calhoun/Liberty Health Careers Summer Camp 2013 APPLICATION Camp Dates: June 17-21, 2013 Graduation Ceremony: June 22, 2013 (Marianna) Held at Bristol Memorial Civic Center NW Theo Jacobs Lane Bristol, FL (All completed applications are due by 4:00 pm on Friday, April 26, 2013) Please type or print legibly (use black ink only). T-shirt size: Name: Last First Middle Mailing Address: City: State: Zip Code: Home Number: ( ) Date of Birth: - - MM DD YYYY Mother or Legal Guardian s Information: Name Home Number ( ) Cell Number ( ) Work Number ( ) Cell Number: ( ) County: Sex: Male Female Father or Legal Guardian s Information: Name Home Number ( ) Cell Number ( ) Work Number ( ) Are you a U.S. citizen? Yes No Permanent Resident? Yes No Country of Birth

3 Ethnicity (Please circle one): African-American/Black (Non-Hispanic) Pacific Islander American Indian/Alaskan Native Asian Hispanic White (Non-Hispanic) Other Is either parent or guardian a graduate of a 4-year college or university? Yes No Is either parent or guardian a graduate of a 2-year college? Yes No Do you have any family members working in the health professions? Yes No If yes, please describe the health profession If you enroll in college, will you become the first member of your immediate family to attend college? Yes No Do you participate in the federally funded free/reduced lunch program at your school? Yes No Current Grade Level: (Only students currently in 9 th, 10 th, or 11 th grade are eligible to apply.) Name of High School: High School Address: Zip Code: City: County: Name of Guidance Counselor (First and Last Name): Mr/Ms/Mrs Phone # Grade Point Average (grades 9 11, through current date): weighted un-weighted (All applicants must have a 3.0 or above grade point average) Please list the science and mathematics courses that you have successfully completed. Attach additional pages if necessary. (All applicants must enclose an official copy of their high school transcript) Course Name Grade Level (9, 10, etc) Grade (A, B, C, etc)

4 List all extracurricular activities in which you participate or have participated in (for example HOSA, volunteer work, sports). Also list special recognitions (such as Honor Roll, science fair awards, etc). Please indicate your desired college major: What are your top 3 choices for a health profession career? (e.g., nursing, physical therapy, medicine, physician assistant, dentistry, etc.) 1) 2) 3) Teacher Evaluations: Please submit two teacher evaluation forms (attached) along with your application and official high school transcript. Please list below the names of the two teachers writing your recommendations. Also list the subjects they teach. Completed teacher evaluation forms must be submitted in separate envelopes with the teacher s signature across the sealed tab. At least one evaluation form must be completed by a science or math teacher. 1) Name Subject 2) Name Subject Personal Essay and Photograph: Please attach a one-page essay which describes your educational and professional goals. Also describe how your participation in the AHEC Health Careers Summer Camp would assist with your college and career plans/aspirations. Your essay must be typewritten (no more than 250 words). Please be sure to spell check and carefully review your essay. This portion of the application is extremely important because it allows us to learn more about you! In addition, please attach a current photograph (head shot facing camera) of yourself. Completed application packets (application, essay and photograph, two sealed evaluation forms, and sealed official transcript) must be submitted by the student applicant or the student s parent. All completed application packets are due by 4:00 p.m. on Friday, April 26, Please submit all application materials to: Big Bend Area Health Education Center Program Attn: Angelika E. Parker 325 John Knox Road, Bldg M, Suite 200 Tallahassee, FL (850)

5 PRIVACY ACT I understand that the information concerning me, my spouse and child as a client will be kept in confidence and will not be revealed to anyone except to the Big Bend AHEC Health Careers Summer Camp personnel in accordance with the Family Educational Rights and Privacy Act. SIGNATURE AUTHORIZATION FORM If selected as an AHEC Health Careers Summer Camp participant, we agree to adhere to the rules, guidelines, and policies of the AHEC Health Careers Summer Camp and its staff. Any failure to obey the aforementioned rules may result in my child s immediate dismissal from the program. GENERAL PHOTOGRAPHY RELEASE I hereby authorize Big Bend Area Health Education Center, Inc., (BBAHEC), to take and publish photographs and/or videos of me during the 2013 Health Careers Summer Camp, and use my name and likeness in print, online, and video-based marketing materials, as well as other company publications. I hereby release and hold harmless BBAHEC from any reasonable expectation of privacy or confidentiality associated with the images specified above. I further acknowledge that my participation is voluntary and that I will not receive financial compensation of any type associated with the taking or publication of these photographs or participation in BBAHEC s marketing materials and publications. I acknowledge and agree that publication of said photos confers no rights of ownership or royalties. I hereby release Big Bend Area Health Education Center, Inc., its contractors, its employees and any third parties involved in the creation or publication of marketing materials, from liability from any claims by me or any third party in connection with my participation. Authorization Printed Student s Name: Printed Name of Parent or Guardian: Printed Street Address: City: State: Zip: Signature of Parent or Guardian: Date (Only one parent/guardian signature is required)

6 TEACHER EVALUATION FORM FOR BIG BEND AHEC HEALTH CAREERS SUMMER CAMP APPLICANT Recommender s Name: (The recommender must be a Science, Health, or Mathematics teacher. At least one recommendation form must be completed by a Science or Health teacher). Name of Applicant: Name of subject you taught applicant and grade level: PART II TEACHER RECOMMENDATION 1. Is this applicant enrolled within a college preparatory curriculum? Yes No 2. To your knowledge, does this student have a history of disciplinary problems? Yes No If yes, please explain. 3. Has the student been recognized for outstanding academics, leadership, or community service? 4. Please assess the personal qualities of this student by checking the most appropriate box for each item listed below. (Place an X in the appropriate category.) 4=Excellent 3=Above Average 2=Average 1=Poor Insufficient basis for judgment Character and Personality Interested in learning Academic motivation Creativity and original thinking Writing skills Work ethic Leadership ability Ability to interact with different groups Ability to work with peers Independence and initiative Reaction to criticism Sense of responsibility Self-discipline and maturity Commitment to service Emotional Stability Overall Evaluation Insufficient basis for judgment Additional Comments: Signature Date Thank you for completing this recommendation for the AHEC Health Careers Summer Camp. Please return this form to the applicant in a sealed envelope with your signature over the seal. All completed applications are due by Friday, April 26, 2013.

7 TEACHER EVALUATION FORM FOR BIG BEND AHEC HEALTH CAREERS SUMMER CAMP APPLICANT Recommender s Name: (The recommender must be a Science, Health, or Mathematics teacher. At least one recommendation form must be completed by a Science or Health teacher). Name of Applicant: Name of subject you taught applicant and grade level: PART II TEACHER RECOMMENDATION 3. Is this applicant enrolled within a college preparatory curriculum? Yes No 4. To your knowledge, does this student have a history of disciplinary problems? Yes No If yes, please explain. 5. Has the student been recognized for outstanding academics, leadership, or community service? 6. Please assess the personal qualities of this student by checking the most appropriate box for each item listed below. (Place an X in the appropriate category.) 4=Excellent 3=Above Average 2=Average 1=Poor Insufficient basis for judgment Character and Personality Interested in learning Academic motivation Creativity and original thinking Writing skills Work ethic Leadership ability Ability to interact with different groups Ability to work with peers Independence and initiative Reaction to criticism Sense of responsibility Self-discipline and maturity Commitment to service Emotional Stability Overall Evaluation Insufficient basis for judgment Additional Comments: Signature Date Thank you for completing this recommendation for the AHEC Health Careers Summer Camp. Please return this form to the applicant in a sealed envelope with your signature over the seal. All completed applications are due by Friday, April 26, 2013.

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