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AHEC Medical Academy 2017 Camp Application
Camp Dates: June 11th - 15th
Please complete all the information requested. Partial or incomplete applications cannot be considered. Camp fees are nonrefundable. Do not send camp fee before you receive an acceptance packet. Applicants must be entering grades 10-12 or have graduated high school in May. If you have any questions, please feel free to call us at (806) 292-6255 or send an email to chris.williams@ahecplains.org.

Camp Fee $75.00

Application deadline is May 5th, 2017

Student Applicant Information
Student's Last Name
Your answer
Student"s First Name
Your answer
Birth Date
Your answer
Gender
Mailing Address( We will be sending camp info and acceptance materials to this address so please provide current, usable mailing address)
Your answer
City, State, Zip
Your answer
County
Your answer
Phone (please specify if home, cell or work)
Your answer
Student's Email
Your answer
Student's Shirt Size
Parent/Guardian Information
Name
Your answer
Phone (please specify if home, cell, or work)
Your answer
Email
Your answer
Relationship to Student
Your answer
Medical Information
Doctor's Name and Phone
Your answer
Insurance Provider
Your answer
Member #
Your answer
Allergic to any medications or foods (if yes, please list)
Your answer
Do you have any dietary restrictions
Your answer
School Information
What grade will you enter in the Fall of 2017
High School
Your answer
High School Phone
Your answer
Counselor Phone
Your answer
Counselor Email
Your answer
Student's GPA
Your answer
Have you ever applied to or attended an AHEC camp?
Education
Please list the science and math courses you have taken in high school and please indicate what grade you earned in each.
Your answer
List all academic honors/awards which you have received or for which you were nominated
Your answer
Are you planning to continue your education after high school? If so, in what way?
Your answer
What career(s) interest you?
Your answer
Extra Curricular
Have you participated in a similar program before? If so, where and when?
Your answer
List any school, church or community activities you have participated in
Your answer
Camp Scholarship
Camp scholarships are available to students in need of assistance for camp fees. Students who receive the summer camp scholarship may attend camp without paying the $75. There are a limited number of scholarships available are scholarships are awarded based on expressed need.
Will you be applying to a camp scholarship?
If you picked yes, please provide a short essay explaining to us why you need the scholarship
Your answer
Essay
Please write one or two paragraphs describing your interest in health careers and how you would benefit from attending this camp. Also include some personality traits you feel make you an appropriate candidate for this summer camp.
Your answer
Signatures of Student and Parent
Students: By checking the box below, you agree that the information you have provided is accurate to the best of your knowledge
Required
Please print name
Your answer
Parent/Guardian: By checking the box below, you agree to allow your student to submit this application to participate in the AHEC Medical Academy 2017 Camp.
Required
Please print name
Your answer
Teacher Recommendation
Your application is not complete until a teacher/counselor recommendation have been submitted. This can be obtained at:
https://drive.google.com/file/d/0B8_Pkez546QqYWJFOF85SDdSazg/view?usp=sharing
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