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SUMMER ENRICHMENT PROGRAM HEALTH CAREERS PROGRAM
ORIENTATION & WORKFORCE TRAINING JUNE 19, 2018 AT 9:00AM-1:00PM
SUMMER INTERNSHIP JUNE 25, 2018-JULY 20, 2018
ELIGIBILITY:
Applicants are required to:
• Be in good academic standing.
• Demonstrate a sincere interest in a specified health care field.
• Understand that ALL internship sites will be located within counties included in the specified AHEC’s region
with an exception to Upstate college students (Upstate AHEC counties included in the region are listed at
www.upstateahec.org).
• Understand that the application process for the Upstate AHEC Summer Enrichment Program is competitive. Submission of this application DOES NOT guarantee acceptance into the program or enrichment opportunities.
• Understand that additional forms and fees are required if accepted to attend the Summer Enrichment Program.
• Inform parents/guardians of possible acceptance.
• Provide transportation to internship placement site and/or the drop-off and pick-up locations for the Summer Enrichment Program if accepted.
DIRECTIONS:
Applications must be TYPED OR PRINTED IN INK.
A non-refundable, $25 application fee must accompany the application.
DEADLINE: ALL applications must be received by MAY 25, 2018.
Completed applications must include:
A COPY OF MOST RECENT REPORT CARD PAYMENT TWO LETTERS OF RECOMMENDATION from a professional and any other adult who is familiar with your academic
work, community service work, or character, and who is NOT a family member, using the enclosedrecommendation sheets.
APPLICATION DEADLINE: MAY 25, 2018
Submit Application along with Check/Money Order in the amount of $25 to: Upstate AHEC
104 South Venture Dr. Greenville, SC 29615
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ALL SECTIONS OF THE APPLICATION MUST BE COMPLETED.
SUMMER ENRICHMENT PROGRAM APPLICATION HEALTH CAREERS PROGRAM
GENERAL INFORMATION:
ARE YOU CONSIDERING TAKING A SUMMER SCHOOL COURSE?
INTERNSHIP SITE:
• I will be able to provide daily transportation to/from sites: • INDICATE YOUR PREFERENCE OF COUNTY: CITY:
STUDENTS SELECTED TO ATTEND THE 2018 SUMMER ENRICHMENT PRORGAM WILL RECEIVE T-SHIRTS.
PLEASE INDICATE T-SHIRT SIZE □ XXL □ XL □ L □ M □ S
IF YOU ARE A COLLEGE STUDENT, ARE YOU WILLING TO SERVE AS A ROLE MODEL FOR A HIGH SCHOOL STUDENT DURING THE SUMMER ENRICHMENT PROGRAM AND FOR THE NEXT ACADEMIC SCHOOL YEAR?
DOES SC AHEC AND UPSTATE AHEC HAVE PERMISSION TO USE PHOTOGRAPHS TAKEN OF YOU FOR ITS WEBSITE, BROCHURES, OR OTHER PUBLICATIONS?
DEMOGRAPHIC INFORMATION:
FULL NAME (FIRST, MIDDLE, LAST)
ADDRESS CITY ZIP
AGE DATE OF BIRTH (MM/DD/YYYY) PLACE OF BIRTH (CITY/COUNTY & STATE)
GENDER SOCIAL SECURITY (XXX-XX-XXXX)
EMAIL PHONE (XXX-XXX-XXXX) CELL (XXX-XXX-XXXX)
RACE/ ETHNICITY:
Yes � No �
Yes � No �
□ LATINO □ CAUCASIAN □ AMERICAN INDIAN □ ASIAN □ MIDDLEEASTERN
□ HISPANIC □ PACIFIC ISLANDER □ NATIVE HAWAIIAN □ AFRICAN AMERICAN □ ALASKA NATIVE
□ NOT LISTED:
Yes � No � Possibly �
Yes � No � Possibly �
**IF YES, PLEASE COMPLETE RELEASE ON PAGE 8.
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FAMILY:
NUMBER OF IMMEDIATE FAMILY MEMBERS CURRENTLY LIVING IN THE HOUSEHOLD (INCLUDING SELF).
_____BROTHERS _____SISTERS _____PARENTS/GUARDIANS _____TOTAL (INCLUDE SELF)
ACADEMIC INFORMATION:
CURRENT ACADEMIC INSITITUTION
ADDRESS CITY STATE ZIP
LAST DAY OF CLASS/ GRADUATION CURRENT ACADEMIC CLASSIFICATION (HIGH SCHOOL: 9, 10, 11, 12 OR COLLEGE: FRESHMAN, SOPHOMORE, JUNIOR, SENIOR)
IF HIGH SCHOOL: GUIDANCE COUNSELOR NAME EMAIL
IF COLLEGE: MAJOR MINOR/ CONCENTRATION
LIST ALL EDUCATIONAL INSTITUTIONS (MOST RECENT FIRST) YOU HAVE ATTENDED:
NAME OF SCHOOL LOCATION GRADUATION DATE DEGREE EARNED
___________________________
_____________________________
____________ ___________ ___________________________
_____________________________
____________ ___________ ___________________________
_____________________________
____________ ___________
LIST ANY HONORS/DISTINCTIONS RECEIVED FOR SCHOLASTIC ACHIEVEMENTS:
_____________________________________ _____________________________________
_____________________________________ _____________________________________ _____________________________________ _____________________________________
LIST ANY EXTRACURRICULAR AND/OR COMMUNITY SERVICE ACTIVITIES (EXCLUDING JOBS HELD DURING YOUR HIGH SCHOOL/COLLEGE YEARS). PLEASE INCLUDE ANY AHEC ACTIVITIES.
_____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________
DATES
DATES
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WORK EXPERIENCE:
LIST ANY JOBS (INCLUDING SUMMER EMPLOYMENT) YOU HAVE HELD IN THE PAST TWO YEARS.
POSITION EMPLOYER DATES OF EMPLOYMENT HRS./WEEK
_________________________ ________________________ __________ to ___________ __________
_________________________ ________________________ __________ to ___________ __________
_________________________ ________________________ __________ to ___________ _________
ESSAY:
USING A SEPARATE SHEET OF PAPER, TYPE A BRIEF ESSAY ANSWERING THE FOLLOWING QUESTIONS:
WHICH HEALTH CAREER ARE YOU MOST INTERESTED IN AND WHY?
HOW DO YOU THINK THAT PARTICIPATION IN THE UPSTATE AHEC SUMMER PROGRAM WILL HELP YOU ACHIEVE YOUR GOAL OF OBTAINING A HEALTH CAREER?
YOU MAY ATTACH RÈSUMÈ &/OR COVER LETTERS TO THIS APPLICATION.
Upstate Area Health Education Center
104 South Venture Drive, Greenville SC 29605
864-349-1175
hcpstudent@upstateahec.org
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EMERGENCY CONTACTS STUDENT INFORMATION
STUDENT PRINTED NAME
ADDRESS CITY ZIP
EMAIL PHONE CELL
PARENT/GUARDIAN NAME ADDRESS (IF DIFFERENT THAN ABOVE)
EMAIL PHONE CELL
IN CASE OF AN EMERGENCY, PLEASE CONTACT THE FOLLOWING: MUST LIST TWO EMERGENCY CONTACTS
CONTACT INFORMATION
EMERGENCY CONTACT NAME RELATIONSHIP
ADDRESS CITY ZIP
EMAIL PHONE CELL
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EMERGENCY CONTACT NAME RELATIONSHIP
ADDRESS CITY ZIP
EMAIL PHONE CELL
EMERGENCY CONTACT NAME RELATIONSHIP
ADDRESS CITY ZIP
EMAIL PHONE CELL
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MEDICAL RELEASE FORM STUDENT INFORMATION
STUDENT PRINTED NAME
- - DATE OF BIRTH SOCIAL SECURITY NUMBER (MM/DD/YYY) (XXX-XX-XXXX)
HEALTH HISTORY
PLEASE LIST ANY ALLERGIES STUDENT HAS:
PLEASE LIST THE NAME, DOSAGE, AND SCHEUDLE OF MEDICATIONS THAT MUST BE TAKEN:
DATE OF LAST TETANUUS SHOT
OTHER CONDITIONS:
HEART CONDITION �DIABETES �ASTHMA �FREQUENT STOMACH ACHE �EPILEPSY �GLASSES / CONTACTS �HAY FEVER �HEARING AID �FREQUENT COLDS �PHYSICAL IMPAIRMENT �PREGNANCY �ACTIVITY RESTRICTION �
IF YOU CHECK ANY CONDITIONS PRESENTED ON THE BOX TO THE RIGHT, PLEASE GIVE DETAILS: (TREATMENT, MEDICATION, IN CASE OF EMERGENCY)
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INSURANCE
* ASTERISKS INDICATES PARENT/LEGAL GUARDIAN’S SIGNATURE REQUIRED IF APPLICANT IS UNDER AGE21
THE INSURANCE PROVIDED BY THE SOUTH CAROLINA AHEC/ UPSTATE AHEC IS ONLY SECONDARY INSURANCE. IF YOU HAVE MEDICAL INSURANCE, YOUR CARRIER WILL BE BILLED FOR MEDICAL CHARGES IN THE CASE OF ILLNESS OR INJURY. WHILE I/MY CHILD AM/IS PARTICIPATING IN AN AHEC-RELATED ACTIVITY OR TRIP, I ASSUME ALL RESPONSIBILITY OF ALL MEDICAL BILLS.
INSURANCE CARRIER POLICY NUMBER
POLICY HOLDER NAME
I ACCEPT THESE TERMS AND CONDITIONS
INITIALS** DATE
IN THE EVENT I AM UNABLE TO PROVIDE INFORMATION DURING AN EMERGENCY, I HEREBY GIVE PERMISSION TO THE MEDICAL PROFESSIONAL SELECTED BY UPSTATE AHEC AND SOUTH CAROLINA AHEC LEADERSHIP TO SECURE PROPER TREATMENT, INCLUDING BUT NOT LIMITED TO: MEDICAL EVALUATION, MEDICAL INJECTION, ANESTHESIA, SURGERY, AND HOSPITALIZATION FOR ME/MY CHILD AS DEEMED NECESSARY.
I ACCEPT THESE TERMS AND CONDITIONS
INITIALS** DATE
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MEDIA RELEASE FORM ’* ASTERISKS INDICATES PARENT/LEGAL GUARDIAN 'S SIGNATURE REQUIRED IF APPLICANT IS UNDER AGE 21
MEDIA
BY SIGNING BELOW I GIVE EXPLICIT PERMISSION FOR UPSTATE AHEC, SOUTH CAROLINA AHEC, AND AFFILIATE ORGANIZATIONS TO USE MY/MY CHILD’S LIKENESS OR IMAGE. USES INCLUDE, BUT ARE NOT LIMITED TO: PHOTOGRAPHY, VIDEOTAPE, ORGANIZATIONAL WEB SITE, OR PRINT MEDIA.
I ACCEPT THESE TERMS AND CONDITIONS
INITIALS** DATE
LIABILITY
I HAVE READ AND UNDERSTAND THIS FORM. I CERTIFY THAT I AM THE ABOVE NAMED STUDENT, OR THAT THE ABOVE NAMED STUDENT IS MY CHILD (OR UNDER MY LEGAL GUARDIANSHIP) AND RESIDES WITH ME IF UNDER AGE 21. I GIVE MY CONSENT TO HIM/HER/SELF TO ATTEND AND PARTICIPATE IN ACTIVITIES, FUNCTIONS AND TRIPS SPONSORED BY THE UPSTATE AHEC AND SOUTH CAROLINA AHEC. I ASSUME ALL TRANSPORTATION COSTS, SHOULD IT BE NECESSARY FOR MY/MY CHILD TO RETURN HOME DUE TO MEDICAL OR DISCIPLINARY ACTIONS.
I ACCEPT THESE TERMS AND CONDITIONS
INITIALS** DATE
I DO HEREBY RELEASE, FOREVER DISCHARGE, AND AGREE TO HOLD HARMLESS UPSTATE AHEC, SOUTH CAROLINA AHEC, ITS STAFF, FACULTY, CHAPERONES AND VOLUNTEERS THEREOF FROM ANY AND ALL LIABILITY, CLAIMS OR DEMANDS FOR PERSONAL INJURY, SICKNESS OR DEATH, AS WELL AS PROPERTY DAMAGE AND EXPENSES OF ANY NATURES WHATSOEVER WHICH MAY BE INCURRED WHILE PARTICIPATING IN ANY ACTIVITY OR TRIP. I ASSUME ALL RISK OF PERSONAL INJURY, SICKNESS, DEATH, DAMAGE AND EXPENSE AS A RESULT OF PARTICIPATION IN RECREATION AND WORK ACTIVITIES INVOLVED THEREIN BY MY CHILD. I UNDERSTAND BY MY SIGNATURE THAT THIS FORM IS BOTH A BINDING MEDICAL AND LIABILITY RELEASE.
STUDENT PRINTED NAME DATE
PARENT/ LEGAL GUARDIAN SIGNATURE ** DATE IF UNDER AGE 21
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HIPPA CONFIDENTIALITY STATEMENT UPSTATE AREA HEALTH EDUCATION CENTER- HEALTH CAREER PROGRAMS
*ASTERISKS INDICATES PARENT/LEGAL GUARDIAN’S SIGNATURE REQUIRED IF APPLICANT IS UNDER AGE 21
I, ______________________________, promise to be respectful of the issues that are discussed in Upstate AHEC’s Health Careers Program. I will not repeat, discuss, share, or communicate “private” and confidential information that is shared at Upstate AHEC, SC AHEC, Volunteer Sites, and Health Care Organizations, nor that is discussed by peers, health care professionals, or the HCP Coordinator/staff that could be misinterpreted or considered “sensitive” in any way.
STUDENT’S SIGNATURE DATE
PARENT/ LEGAL GUARDIAN SIGNATURE ** DATE IF UNDER AGE 21
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