AHEC of a Summer Health Careers Volunteer Program

2018 AHEC of a Summer Health Careers Volunteer Program Application for Vermilion Parish DEADLINE: Friday, February 23rd Submit Application to: High School Guidance Counselor

Note: In addition to on-line access, applications are being distributed in each parish by school system personnel.

Applications must be completely filled out by the student in black ink only. Student must legibly print or type. Student’s Legal Name: ______Parish: ______Address: ______School: ______City, State, Zip: ______Current year in school: 9 10 11 Home Phone: (_____) ______Gender: Male Female Date of Birth: ______Age: ______Student’s Email Address (make sure the email address you provide is one that you check FREQUENTLY. This is how you will be contacted and updated on your progress: ______Please print clearly – as this is a very important means for communication

HRSA requires that AHECs report data on race and ethnicity for federal statistics, program administrative reporting, and civil rights compliance.

Race (check those that apply; optional --- for Federal Reporting purposes) _____ American Indian _____ Asian _____ African American _____ Pacific Islander _____ Caucasian _____ Other Ethnicity (Check one; optional --- for Federal Reporting purposes) _____ Hispanic _____ Non-Hispanic

What is your high school semester grade for Biology or General Science? ______*Please attach a copy of your high school transcript to this application. It doesn’t have to be an “official” copy, just a print out from your counselor. Do you have reliable transportation to the program location? Yes______No ______Parent/Guardian Names ______Parent/Guardian Addresses (if different from student’s) ______Mother Father Parent/Guardian Work Phone ______Parent/Guardian Cell Phone ______Parent/Guardian Alt. Phone ______

*Acceptance into the AHEC of a Summer program requires an enrollment fee of $15 and a commitment of approximately 90-100 total hours of weekday volunteer service at designated health care facilities in early June. Volunteers do NOT receive wages or salary through the AHEC of a Summer program. Signing this application is an indication of your availability and commitment to participate in ALL scheduled AHEC of a Summer days and activities. **Money should NOT be sent with this application.**

Applicant signature: ______Date: ______Parent/guardian signature: ______Date: ______Return the completed application to the person designated below: Your High School Counselor

This program is a cooperative service of the Southwest Louisiana Area Health Education Center, parish school boards, local hospitals, clinics, and other health care facilities and offices.

From time to time, students will be contacted by Southwest Louisiana AHEC as a follow-up to this experience.

Attached at the end of this application are instructions for Letters of Reference. Please give one to each of the people providing a letter. Be sure to fill in your name and school on the top of each page.

List the name of all high school science classes which you have taken or are currently enrolled: ______How did you learn about the AHEC of a Summer Health Careers Volunteer Program? ______

Are any members of your immediate family employed in a health care profession? Yes ______No______If yes, what profession?______Are you considering a career in health care? Yes ______No ______Unsure ______If yes, what would you like to do? ______Have you ever worked in a health care facility as a volunteer or employee? Yes______No_____ If yes, where, when, and what was your job? ______If you had a choice, which hospital department would you be most interested in? Please write your choice and explain why. Dietary Laboratory Emergency Room Occupational Therapy Nursing Radiology Respiratory Therapy Physical Therapy Health Information Management Dietary Other ______Uniform Size Information Note: These are in unisex sizes, please choose accordingly. Keep in mind the uniform should be loose fitting. It is better to order a little too large than too small. The scrubs come in sets. We cannot make exchanges, or mix top and bottom sizes.

Size XS S M LG XL 2X ___ 3X 4X _ 5X __ Bust/chest 35-36 37-39 40-43 44-47 48-50 51-53 54-57 58-60 61-64 Waist 26-27 28-31 32-34 35-38 39-41 42-45 46-49 50-53 54-57 Hip 37-38 39-41 42-45 46-48 49-52 53-56 57-59 60-63 64-67

What size scrub set would you like? Please note that sizes 4X & 5X will require an additional $10 fee ______Would you like to order an additional set of scrubs? Yes______No______(One set will be provided at no charge to you. A second set is recommended as scrubs must be cleaned daily.) Cost: $14.00/set for additional sets plus additional $10 for sizes 4X & 5X (do not include money with this application)

ESSAYS: You must legibly write a minimum of five complete sentences to be accepted into the program. Why do you wish to participate in the AHEC of a Summer Program and what do you hope to gain from the experience?

______Why do you have an interest in a career in health care? Explain what caused you to have that interest:

______Have you ever participated in any volunteer, extracurricular, or community activities? Describe and tell us what you learned from those experiences. ______

Attached below are three Recommendation Forms. One must be completed by each of the following: 1) One of your former or current science teachers. 2) One of your extracurricular sponsors or coaches. 3) One of your current teachers (other than science).

You should provide each teacher with an envelope to put the letter into. The envelope should be sealed and signed over the seal so that their responses remain anonymous. Include all three recommendation forms in their signed and sealed envelopes in your application packet that you submit to your counselor.

Southwest Louisiana Area Health Education Center AHEC of a SUMMER Student Volunteer Program

Teacher Recommendation Form Applicant Name: ______Current School: ______Teacher Name: ______Subject/Activity: ______

The above named student has applied to the 2018 AHEC of a SUMMER volunteer program and has been asked to submit this form for reference. This is an amazing opportunity for the applicant to experience Health Care Careers. Please complete this recommendation form and return ASAP to the student in the envelope they provided to you.

These forms are confidential and will not be shared with the applicant. Your open and honest communication is critical as we are placing these students in local hospitals to work with professionals.

Please check one Excellent Good Fair Poor Punctuality Timely Completion of Assignments Class Participation Social Relationship with Peers Ability to Work in Groups Stays on Tasks Character (Honesty, Attitude, etc.) Relationship with Adults Respect for Authority Discipline/Behavior in Class Please check one. Overall Recommendation: Highly Recommend Recommend Recommend with Reservations Do NOT Recommend

Teacher Signature: Date:

Please take a moment to comment on your personal experience with the applicant as it will be used in the selection process. You may continue on the back of this form if additional space is needed. ______

Southwest Louisiana Area Health Education Center AHEC of a SUMMER Student Volunteer Program

Teacher Recommendation Form Applicant Name: ______Current School: ______Teacher Name: ______Subject/Activity: ______

Please complete this recommendation form and return ASAP to the student in the envelope they provided to you.

These forms are confidential and will not be shared with the applicant. Your open and honest communication is critical as we are placing these students in local hospitals to work with professionals. Please check one Excellent Good Fair Poor Punctuality Timely Completion of Assignments Class Participation Social Relationship with Peers Ability to Work in Groups Stays on Tasks Character (Honesty, Attitude, etc.) Relationship with Adults Respect for Authority Discipline/Behavior in Class Please check one. Overall Recommendation: Highly Recommend Recommend Recommend with Reservations Do NOT Recommend

Teacher Signature: Date:

______Southwest Louisiana Area Health Education Center AHEC of a SUMMER Student Volunteer Program

Teacher Recommendation Form Applicant Name: ______Current School: ______Teacher Name: ______Subject/Activity: ______

Please complete this recommendation form and return ASAP to the student in the envelope they provided to you.

These forms are confidential and will not be shared with the applicant. Your open and honest communication is critical as we are placing these students in local hospitals to work with professionals.

Teacher Signature: Date:

Applicant’s Name: ______Grade: _____ Age:______

School: ______Parish: ______

______FEMALE ______MALE

1. Application returned by due date _____/5 2. Application form completed correctly _____/3 3. Application signed by student & parent _____/2 4. 2016-2017 School Year Grade Level (9th=5, 10th=7, 11th=10) _____/10 5. General Science or Biology Grade (A=10, B=7, C=5, D=1, F=0) _____/10 6. Impression of hospital department volunteer choice question _____/5 7. Impression of essay answer #1 _____/10 8. Impression of essay answer #2 _____/10 9. Letter of Reference #1 _____/10 10. Letter of Reference #2 _____/10 11. Letter of Reference #3 _____/10 12. Previous volunteer work experience/school service clubs _____/10 13. Copy of High School transcript included _____/5

Overall Rating: (75-100 points = acceptable score) TOTAL _____/100

Recommended for Program: ______YES ______NO

Evaluator: ______Date: ______

Each application must have a comment if denied.

Comments: ______

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