SUMMER HEALTHCARE PROGRAM APPLICATION FORM (Please print clearly) Student’s Name: Address:
Telephone: Date of Birth:
Street City
State
Zip
Male
Email: Female
Name of school district the student resides in: In the Fall of 2017, the student will be entering what grade? Circle the number beside the area(s) of Health Care you are interested in? 1. Emergency room 2. Operating room / surgery area 3. Nursing & patient areas 4. Lab /pharmacy 5. Radiology
6. Physical therapy / home health 7. Facilities (plant engineering/food service/housekeeping) 8. Administration (leadership/medical records/accounting) Other___________________________________
Does the student have any physical limitations that will prevent him/her from participating in this program? Does the student have any allergies?
Yes
No
If so, please list: Please list any medications: Mother’s Name:
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