PARENTAL PERMISSION TO ATTEND HEALTH ... - Centra Health



HEALTH CAREER CAMP APPLICATION 2016NAME: FORMTEXT ????? DATE: FORMTEXT ?????ADDRESS: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? (Street) (City) (State) (Zip)TELEPHONE: FORMTEXT ?????CELL PHONE: FORMTEXT ????? AGE: FORMTEXT ??? BIRTHDATE: FORMTEXT ?????EMAIL ADDRESS: FORMTEXT ?????SCHOOL YOU ATTEND: FORMTEXT ????? YEAR YOU WILL GRADUATE: FORMTEXT ?????IF HOME SCHOOLED PLEASE INDICATE BY WRITING YES: FORMTEXT ?????DO YOU HAVE AT LEAST A 2.5 (C) CUMMULATIVE GPA AT THIS TIME? YES FORMCHECKBOX NO FORMCHECKBOX NAME OF PARENT/GUARDIAN: FORMTEXT ?????ADDRESS IF NOT THE SAME AS ABOVE: FORMTEXT ????? (Street) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? (City) (State) (Zip)PARENT’S HOME PHONE #: FORMTEXT ????? PARENT’S ALTERNATE PHONE #: FORMTEXT ?????COMMUNITY INVOLVEMENT (CHURCH, VOLUNTEER, ETC.): FORMTEXT ?????HOBBIES, SKILLS, SPECIAL INTERESTS: FORMTEXT ?????WHAT AREAS OF HEALTH CARE ARE YOU INTERESTED IN EXPLORING? FORMTEXT ?????____ Registration fee of $30.00 enclosed. Please make check out to Centra.ESSAYSOn a separate sheet of paper, please write your responses to the following two questions. The essays are the determining factor for acceptance into the camp. For this reason grammar, spelling and content will be considered in reviewing your responses. Self-awareness is critical in healthcare careers, so these questions are designed to help us understand you and your desire to explore these career options.IN 250 WORDS OR LESS DESCRIBE YOURSELF.ANSWER EACH OF THE FOLLOWING QUESTIONS IN 250 WORDS OR LESS:WHY YOU WANT TO ATTEND THE HEALTH CAREER CAMP AND WHAT YOU EXPECT TO GET OUT OF IT.WHY YOU FEEL A CAREER IN HEALTH CARE MIGHT BE RIGHT FOR YOU.HEALTH CAREER CAMP RECOMMENDATIONTO BE COMPLETED BY HIGH SCHOOL COUNSELORSTUDENT NAME: FORMTEXT ????? DATE: FORMTEXT ?????Attitude of Student: FORMCHECKBOX Enthusiastic FORMCHECKBOX Interested FORMCHECKBOX Indifferent FORMCHECKBOX Lacks Self-Control Displayed behaviors that warrant rating above: FORMTEXT ?????GPA: FORMTEXT ?????(To qualify, student must have at least a 2.5 Avg. GPA or C average to date)Has this student spoken to you about an interest in Health Care as a career choice? FORMCHECKBOX Yes FORMCHECKBOX NoIs this student a going to be a junior in High School for the school year 2016-2017? FORMCHECKBOX Yes FORMCHECKBOX NoYear student will graduate High School FORMTEXT ?????Home Schooled: FORMCHECKBOX Yes FORMCHECKBOX NoDo you feel that a career in Health Care is an appropriate choice for this student? Why or why not? FORMTEXT ?????Comments: FORMTEXT ?????Signature of Counselor: FORMTEXT ????? Date: FORMTEXT ?????Name of Counselor: FORMTEXT ????? Phone: FORMTEXT ?????High School: FORMTEXT ????? Email: FORMTEXT ?????PLEASE FAX, EMAIL, OR MAIL THIS FORM TO LISA STEWARTCENTRA, VIRGINIA BAPTIST HOSPITAL3300 Rivermont Ave, LYNCHBURG, VA 24503FAX: 434-200-4056/EMAIL: Lisa.Stewart@FORMS MUST BE RECEVIED NO LATER THAN 5:00 p.m. ON April 18, 2016HEALTH CAREER CAMP RECOMMENDATIONTO BE COMPLETED BY MATH OR SCIENCE TEACHERSTUDENT NAME: FORMTEXT ????? DATE: FORMTEXT ?????Attitude of Student: FORMCHECKBOX Enthusiastic FORMCHECKBOX Interested FORMCHECKBOX Indifferent FORMCHECKBOX Lacks Self-ControlDisplayed behaviors that warrant rating above: FORMTEXT ?????GPA in your class: FORMTEXT ????? (To qualify, student must have at least a 2.5 Avg. GPA or a C average to date)What subject is the student taking under your instruction? FORMTEXT ?????Does the student express a consistent interest in math or science? FORMTEXT ?????Has this student spoken to you about an interest in Health Care as a career choice? FORMCHECKBOX Yes FORMCHECKBOX NoIs this student going to be a junior in High School for the school year 2016-2017? FORMCHECKBOX Yes FORMCHECKBOX NoDo you feel that a career in Health Care is an appropriate choice for this student? Why or why not? FORMTEXT ?????Comments: FORMTEXT ?????Signature of Teacher: FORMTEXT ????? Date: FORMTEXT ?????Name of Teacher: FORMTEXT ????? Phone: FORMTEXT ?????High School: FORMTEXT ????? Email: FORMTEXT ?????PLEASE FAX, EMAIL, OR MAIL THIS FORM TO LISA STEWARTCENTRA, VIRGINIA BAPTIST HOSPITAL3300 Rivermont Ave, LYNCHBURG, VA 24503FAX: 434-200-4056/EMAIL: Lisa.Stewart@FORMS MUST BE RECEVIED NO LATER THAN 5:00 p.m. ON April 18, 2016Date: FORMTEXT ?????To:Parent/GuardianSubject:Consent for Vaccination/TestingI give permission and consent to the Healthworks office physician or nurse to administer examinations, treatment or testing that is deemed medically necessary to meet the CDC/OSHA requirements for Healthcare facilities including the administration of the following tuberculosis skin test and/or vaccination(s) to my child. FORMCHECKBOX TDAPX TB skin test FORMCHECKBOX Hepatitis B FORMCHECKBOX MMR (Measles, Mumps & Rubella) FORMCHECKBOX Varivax (Chicken pox) FORMCHECKBOX Flu Vaccine FORMTEXT ?????Name of ChildParent/Guardian SignatureDate********************************************************************************************PARENTAL PERMISSION TO ATTEND HEALTH CAREER CAMPPermission is granted for my daughter/son FORMTEXT ?????to participate in the Health Career Camp to be held at CENTRA and to observe in approved hospital services. I understand that CENTRA will assume no responsibility for the above named student prior to or following her/his published camp times. Furthermore, I agree to see that my child is provided with transportation to and from CENTRA and will be dressed in appropriate attire for participation in this camp.SIGNATURE: FORMTEXT ?????DATE FORMTEXT ????? (Parent/Guardian)PLEASE PRINT NAME OF PARENT/GUARDIAN: FORMTEXT ????? ................
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