Sanford Scrubs Club Application

Contact Information

Name

Street Address

City ST ZIP Code

Cell Phone

Home Phone

School and Grade

E-Mail Address

Parent/Guardian

Parent/Guardian Phone in case of emergency

Tell us why you are interested in learning about healthcare careers: Sanford Scrubs Club Application

Please list school activities, work times, and the number of hours per week you are involved. Activity Hours Activity Hours Activity Hours

Your Commitment

Check one: School year ___ Summer ____

The school year program will be held on the 3rd or 4th Thursday, September through April, from 6:30pm to 8:00pm.

Your commitment to the program upon acceptance is essential. One un-excused absence or 2 excused absences will be allowed for the school year program.

Summer program consists of 3 consecutive days in June (TBD) from 1:00pm to 3:00pm. Attendance to each day is essential.

I commit to the program’s attendance policy.

Student’s Signature Date

As parent/guardian of this applicant, I support his/her participation in and commitment to the Sanford Scrub’s Club experience.

Parent’s /Guardian’s Signature Date

Important

School Year Program Application Deadline: September 10th Summer Program Application Deadline: May 10th

All applicants will be notified in writing of the selection committee’s decision

Send completed application to: Sanford USD Medical Center 1305 W 18th St PO Box 5039, Sioux Falls, SD 57117-5039 Attention: Kelly Tollefson /Workforce Development

Fax: 605-333-6304 or email: [email protected]