St.Vincent Health Career Opportunity Program to Increase Needed DiversitY (HCOP INDY) June 16, 2014 - July 25, 2014 Enter to learn...leave to serve Metropolitan Indianapolis-Central Indiana Area Health Education Center ENROLLMENT CRITERIA: Student MUST live in Marion County Student is economically and/or educationally disadvantaged Entering 9th-12th grades FOCUS ON: Cultural Competency Self-Discovery Academic Enrichment SAT/ACT Prep Knowledge of healthcare fields College readiness Hoosier Health Academy $1,200 Student Stipend Applications accepted up until: Friday, May 9, 2014 at 5:00pm (NO exceptions) Applications received after this date will not be considered Hoosier Health Academy is a six-week summer academic and enrichment program for high school students with an interest in the healthcare field. The Academy is full of academic enrichment through the use of interactive and experiential learning techniques that allow students to explore math and science. Student will learn skills needed to pursue and graduate from college. Location of Hoosier Health Academy Program will be held at Marian University, 3200 Cold Spring Road, Indianapolis, IN, 46222. The program will be held from 9:00am to 3:00pm, Monday through Friday. Fully Completed Applications may be submitted to: Metropolitan Indianapolis Central Indiana Area Health Education Center ATTN: HCOP 9101 Wesleyan Road, Suite 310 Indianapolis, IN 46268 ** We encourage applicants to apply and send in their applications early or fax to 317-583-4112 **
HOOSIER HEALTH ACADEMY Application Form ENROLLMENT CRITERIA: Student MUST live in Marion County and be economically and/or educationally disadvantaged. Applicant MUST also be a U.S. citizen or prove legal residency. Students who are entering 9th grade through current 12th graders. Application Checklist (All should be submitted for a completed application): Complete Application form Academic Transcript (official or unofficial will be accepted) 3 Recommendation Forms filled out in addition to a recommendation letter attached from each recommender: 2 academic letters, 1 personal letter Personal Statement A personal statement is written by the applicant and may include personal history, career interest, why you are interested in this program and how this may help the student. Please make this no longer than two typed, doublespaced pages. TYPE OR PRINT VERY CLEARLY Student Name Gender: Female Male Date of Birth: Age: Current Grade: Name of School: Are you a JAG student? Yes No Health career area of Interest: GPA: /4.0 scale Shirt Size: Student Cell Phone: Home Phone: Student Email: Street Address: City: State: Zip Code: Parent/GuardianName(s): Parent Daytime Phone: Parent Email Address: Race (Check all that apply): African American/Black Hispanic White/Non-Hispanic Asian American Indian/Alaskan Native Other (please specify) Would you be the first in your immediate family to graduate from a college or university? Yes No How did you hear about the program? Teacher Family HCOP representative Presentation at school (KIHC) Internet How interested in health care are you: Very Somewhat Not really Not sure yet Have you applied for an HCOP program in the past? Yes No If yes, which program? I hereby certify that the information provided in this application is accurate to the best of my knowledge. I understand that providing false information can result in dismissal from the program if I am accepted to the program. I understand that submitting this application does not guarantee admission to the Program. Applicant Signature: Date: Parent/Guardian s signature: Date:
Academic Recommendation Form I have known the applicant for a period of in the following capacity: Please check one Math Teacher Science Teacher Counselor Other, indicate: The applicant ranks academically with other students I have taught in recent years as follows: Top 5% Top 10% Top 25% Average Below Average Please rank the applicant on the following traits, relative to the other students you have taught. with Reservations Please attach a 1 2 paragraph description of your reasons for recommending this student. Name: Title: Department: School Name Address: City/State/Zip: Phone number where you can be reached: Signature: Date:
Academic Recommendation Form I have known the applicant for a period of in the following capacity: Please check one Math Teacher Science Teacher Counselor Other, indicate: The applicant ranks academically with other students I have taught in recent years as follows: Top 5% Top 10% Top 25% Average Below Average Please rank the applicant on the following traits, relative to the other students you have taught. with Reservations Please attach a 1 2 paragraph description of your reasons for recommending this student. Name: Title: Department: School Name Address: City/State/Zip: Phone number where you can be reached: Signature: Date:
Personal Recommendation Form I have known the applicant for a period of Relationship to applicant: Family member recommendations will not be accepted. Please rank the applicant on the following traits, relative to the other students/young people you know. with Reservations *Please attach a 1 2 paragraph description of your reasons for recommending this student. Name: Company Name Title: Address: City/State/Zip: Phone number where you can be reached: Signature: Date: