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AHEC Presents Tech MED Camp 2017
Tech Medical Education Development Camp

When: Sunday, June 11th, 2017 to Thursday, June 15th, 2017

Where: At Texas Tech University, Lubbock Texas

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 9-12 or have graduated high school in May. Accepting campers age 14 - 17 years old.

Camp Fee $50.00 (paid after accepted to camp)

Application Deadline is May 4th, 2017

If you have any questions, please email WTxAHEC@ttuhsc.edu

Email address
Student Application 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
Student's Phone Number (please specify if home, cell or work)
Your answer
Student's Email
Your answer
Parent/Guardian Information
Name
Your answer
Relationship to Student
Your answer
Parent/Guardian Phone (please specify if home, cell or work)
Your answer
Parent/Guardian Email
Your answer
Medical Information
Doctor's Name and Phone Number
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
School Information
What grade will you enter in the Fall of 2017?
High School Name
Your answer
High School Phone Number
Your answer
Counselor's Email
Your answer
Counselor's Phone
Your answer
Student's GPA (Currently there is no minimum required)
Your answer
Have you applied to or attended an AHEC Camp before?
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 Activities
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 Scholarships
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 $50. There are a limited number of scholarships available are scholarships are awarded based on expressed need.
Will you be applying for 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/Guardian
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 your 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 Health Careers Camp 2017.
Required
Please print your name
Your answer
Teacher Recommendations
Your application is not complete until a teacher/counselor recommendation have been submitted. Please email fax or mail the completed application & teacher recommendation by May 4, 2017. You can submit the form by any of the following:
Mail to: West Texas AHEC
4430 South Loop 289 suite 300
Lubbock, Texas 79416
Fax: (806) 743-3626 Or email complete form to WTxAHEC@ttuhsc.edu

The recommendation form is available in the below link:

https://drive.google.com/file/d/0B7vIxzdmhnu6aFVNSUVXRm0yQ0U/view?usp=sharing

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