Health Careers Camp
June 8-11, 2009
Baylor University, Waco, Texas
Please complete these application materials and return to your teacher.
Teachers, please mail complete application packet to:
Brazos Area Health Education Center
c/o Todd Becker
1722 Colcord Ave.
Waco, TX 76707
For questions, please contact Todd Becker: (254)753-4392, ext. 14
tbecker@bahec.org
Health Careers Camp
Participant Application
Please
print clearly.
Name__________________________________
Mailing
Address_________________________________________________
City_________________________
State____
Zip Code____________
Home
Phone_(_____)_______________
Email___________________________________________________________
Parent/Guardian Name
1.______________________________________
Relation________________
Daytime
Phone_(_____)____________
Cell phone _(_____)______________
Occupation,
Work Phone _________________________(_____)____________
2.______________________________________
Relation_________________
Daytime
Phone_(_____)____________
Cell phone _(_____)______________
Occupation,
Work Phone _________________________(_____)____________
In case of
emergency, contact:
Name_____________________
Phone:_(_____)_______________
Relation________________________
Current
School____________________ City________________ County____________
Counselor’s
Name___________________
Phone_(_____)_______________
What is your
current grade level?___________________________
How did you
find out about Health Careers Camp? (Check all that apply)
___ Math
Teacher
___ Guidance Counselor
___Coach
___ Science
Teacher
___ Newspaper
___ Friend
___ Health
Teacher
___ AHEC Website
___Other: _____________
Are you
planning to continue your education after high school?
If so, in what way? (e.g.
training program, junior college, university, military, technical school)
___________________________________________________________________
___________________________________________________________________
Have you
participated in a similar program before?
If so, where and when?
___________________________________________________________________
___________________________________________________________________
List any of
your school, church, and community activities.
_________________________________________________________________
_________________________________________________________________
Do you have
any hobbies or special interests?
___________________________________________________________________
___________________________________________________________________
What careers
interest you?
___________________________________________________________________
___________________________________________________________________
Is there any
reason why you would be unable to attend the camp in its entirety?
(9:45 a.m.
on Monday, June 8th until 3:00 p.m. on Thursday, June 11th
2009)
___________________________________________________________________
Essay
In the space
provided below, please explain why you are interested in attending Health
Careers Camp. List your interests
in health careers and what you plan to gain from attending this camp.
Include personal characteristics that make you a candidate for the
program.
Applicant
Signature_________________________________ Date _______________
Parent/Guardian Signature___________________________ Date _______________
Teacher
Recommendation
Student
Applicant:
Recommendations from two teachers are required. Please make a copy of this page
and the three that follow it. Give
a copy to two different teachers.
Give
the completed application material (application, essay, and these teacher
recommendation forms) to one of the teachers and ask them to please mail it for
you.
Please fill
out the information on this page.
Give the completed application material (application, essay, and this form) to
your teacher to mail.
Applicant
Name (print) ________________________________________________
Applicant’s
Waiver of Right of Access to Confidential Statements:
I hereby
freely and voluntarily waive my right of access to any information contained on
this recommendation form, and agree that all statements shall remain
confidential.
Applicant
Signature_________________________________ Date _______________
Parent/Guardian Signature___________________________ Date _______________
Teacher:
The student whose name appears above is applying for admittance to the Health
Careers Camp sponsored by Brazos AHEC.
Your candid estimate of academic performance, intellectual promise, and
personal qualities is important to the selection committee in making final
selections for this camp. Because
of federal legislation giving students access to education records, we cannot
guarantee the confidentiality of your statement unless
the applicant and his/her
parent/guardian have signed the waiver printed above.
Please fill
out the recommendation and mail application in entirety to:
Brazos Area Health Education Center
c/o Todd Becker
1722 Colcord Ave.
Waco, TX 76707
*Application
materials should be postmarked by
Friday,
April 24, 2009.
If you have any questions about this application or Health Careers Camp, please
contact Todd Becker at Brazos AHEC.
Teacher
Recommendation
How long
have you known this applicant?
What
subjects have you taught this applicant?
To your
knowledge, does this applicant express any interest in a future health career?
If so, please elaborate.
Accessibility to healthcare institutions at future summer career camps depends
on the maturity level and behavior of students each year.
Please comment on this applicant’s ability to behave in professional and
potentially stressful environments.
Teacher’s
overall recommendation of applicant for Health Careers Camp:
Please
indicate the strength of your overall endorsement of this applicant by placing a
single check mark in ONE of the boxes below:
|
Outstanding
Top
10% |
Very
Good
Top
25% |
Satisfactory
Top
50% |
Average
Lower 50% |
No
Basis for Judgment |
|
|
|
|
|
|
Below,
please comment on this applicant’s performance and potential to benefit from
this camp.
___________________________________________________________________
Signature of
Teacher
Date
___________________________________________________________________
Printed Name
of Teacher
Phone
Email
______________________________________________________________
Name of
School _____________________________________________________
Address
___________________________________________________________
City
State
Zip
Camp
Withdrawal and Refund Policy
We
understand that occasionally unexpected circumstances arise in which students
need to withdraw from camp. As a
result, we have implemented a Camp
Withdrawal and Refund Policy. This policy allows for a complete refund of
the camp registration fee ($300). The stipulations of this policy are listed
below and must be met completely to receive the refund.
Deadline:
The camp withdrawal and refund request must be postmarked by Friday, May
22, 2009. The request must be made by letter and must state the reason for
withdrawal. Acceptable
circumstances are listed below.
Justifications for Withdrawal:
Circumstances for withdrawal are limited to either family emergency
(illness, accident, death) or disciplinary action from the student’s school.
Official documentation of the disciplinary action taken by your student’s
school must be provided along with your letter requesting withdrawal from
attending camp.
You will be
notified upon receipt of your request letter.
Please allow
four to six weeks for processing and check disbursement of the camp withdrawal
and refund request.
My signature
below attests that I have read and understood the
Camp Withdrawal and Refund Policy.
Applicant
Signature_________________________________ Date _______________
Parent/Guardian Signature___________________________ Date _______________