<p> Sanford Scrubs Club Application </p><p>Contact Information</p><p>Name</p><p>Street Address</p><p>City ST ZIP Code</p><p>Cell Phone</p><p>Home Phone</p><p>School and Grade</p><p>E-Mail Address</p><p>Parent/Guardian </p><p>Parent/Guardian Phone in case of emergency</p><p>Tell us why you are interested in learning about healthcare careers: Sanford Scrubs Club Application </p><p>Please list school activities, work times, and the number of hours per week you are involved. Activity Hours Activity Hours Activity Hours</p><p>Your Commitment</p><p>Check one: School year ___ Summer ____</p><p>The school year program will be held on the 3rd or 4th Thursday, September through April, from 6:30pm to 8:00pm. </p><p>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.</p><p>Summer program consists of 3 consecutive days in June (TBD) from 1:00pm to 3:00pm. Attendance to each day is essential.</p><p>I commit to the program’s attendance policy.</p><p>Student’s Signature Date</p><p>As parent/guardian of this applicant, I support his/her participation in and commitment to the Sanford Scrub’s Club experience.</p><p>Parent’s /Guardian’s Signature Date</p><p>Important</p><p>School Year Program Application Deadline: September 10th Summer Program Application Deadline: May 10th </p><p>All applicants will be notified in writing of the selection committee’s decision</p><p>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</p><p>Fax: 605-333-6304 or email: [email protected]</p>