2013 AHEC-BSU-NTC SCRUBS Camp, Focus on Health Care

2013 AHEC-BSU-NTC SCRUBS Camp, Focus on Health Care

NW MN Area Health Education Center (AHEC) Application Form

SCRUBS Camp, Focus on Health Care

to be held atBemidji State University, July 31 – August 1, 2013

Application Form for 2013-14 school year 8th-10th grade students

Please return completed application along with $95 non-refundable payment to:

NW MN AHEC

Attn: Joan Tronson, Executive Director

323 S. Minnesota St

Crookston, MN 56716

If you have questions, please email Joan Tronson, Executive Director, NW MN AHEC at r call her at 218-281-9216.

PERSONAL INFORMATION

Name:______Date: ______/______/______Gender: ?M ?F

Home Address: ______Date of Birth:______/______/______Age: ______

City, State, Zip: ______Phone:______

Grade in 2012-13: ______School: ______Email Address: ______

Parent/Guardian #1: ______Parent/Guardian #2______

Daytime Phone: ______Daytime Phone:______

Email Address:______Email Address:______

Shirt size (adult size): ?XS ?S ?M ?L ?XL (participants receive a t-shirt at camp)

SCHOOL/CAREER EXPLORATION INFORMATION

Favorite Classes in School:

______

Least Favorite Classes in School:

______

What career(s) would you like to have when you are an adult?

______

Do you plan to attend college? ?Yes ?No ?I am not sure

If you plan to attend college, how many years are you planning to attend? ? 2? 4 ? 4+

What do you like to do in your spare time? (hobbies, sports, etc)

______

Please check the top three health careers you may have an interest below:

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2013 AHEC-BSU-NTC SCRUBS Camp, Focus on Health Care

NW MN Area Health Education Center (AHEC) Application Form

___ Doctor / Medicine

___ Pharmacy

___ Dentistry

___ Nursing

___ Physical Therapy

___ Occupational Therapy

___ Veterinary Medicine

___ Public Health

___ Laboratory

___ Radiology

___Speech Therapy

___ Other:______

Scrubs Camp July 31-August 1, 2013Page 1

2013 AHEC-BSU-NTC SCRUBS Camp, Focus on Health Care

NW MN Area Health Education Center (AHEC) Application Form

Scrubs Camp July 31-August 1, 2013Page 1

2013 AHEC-BSU-NTC SCRUBS Camp, Focus on Health Care

NW MN Area Health Education Center (AHEC) Application Form

EMERGENCY INFORMATION (if different from parent/guardian)

Emergency Contact Name / Relationship / Area Code and Phone Number(s)

ADDITIONAL INFORMATION – Answering these questions is voluntary. SCRUBS uses this data to apply for and receive grant funds to help keep camp costs low.

Is there other important information the program should know about you (behavioral difficulties, custody issues, special education needs, etc.)

Has anyone in your immediate family (mom, dad, brother, sister) earned a 4-year/Bachelors degree?

?Yes ?No ?I am not sure

Primary Language spoken at home: ______

Ethnic Background:

?American Indian/Alaskan Native

?Asian/Pacific Islander

?Hispanic

?Black (not of Hispanic origin)

?White (not of Hispanic origin)

?Other: ______

I have agreed to apply (or apply for my child) to participate in the Minnesota SCRUBS Camp(SCRUBS CAMP) program. To the best of my knowledge, all questions in this application have been answered accurately. I agree that he/she mayparticipate in the SCRUBS CAMP program. I understand that daily attendance and appropriate behavior is required andexpected. Furthermore, I understand that inappropriate behavior may result in me/my child being removed from the program.

______/______/______

Signature of Applicant Date

______/______/______

Signature of Parent/Guardian Date

MEDICAL/DISABILITY INFORMATION

Health History: (list type of health problem, severity and frequency of occurrence):

Allergies: ? No ? Yes (describe):

______

Seizure: ? No ? Yes (describe):

______

Restricted Activities: ? No ? Yes (describe):

______

Dietary Needs: ? No ? Yes (describe):______

Any accommodations or special help you need at camp? ? No ? Yes (describe):

______

IMPORTANT: If your son/ daughter must take medications, vitamins or supplements while at camp, they must be listed on this form and reviewed by a physician. All medications must be sent to camp in their original prescription containers/bottles.

Medication Name / Dose (How much is given each time) / Frequency: (times of day meds are given) / What is medication given for / Changes/Notes
Staff Only

PLEASE SEND ENOUGH MEDICATION WITH YOUR SON/DAUGHTER

Private Insurance (HMO, PPO, Medical) Name______

Private InsurancePolicy Number:______

Primary Care Physician Name: ______Phone:( ) ______-______

Primary Care Dentist Name: ______Phone: ( ) ______-______

I, the undersigned, hereby represent that I am 18 and my own legal guardian, or the parent/ legal guardian of this student, and state that the health history is correct so far as I know. I consent that in the event of sickness or accident of any nature, the MN SCRUBS Camp(SCRUBS CAMP) program will not be held responsible or liable. With the realization that in such eventuality personal notification may not be possible or practicable, I authorize the SCRUBS CAMP program staff to render any aid and assistance to help me/ my son/ daughter; to call a physician or dentist, if necessary, who may take any measure, including surgery and hospital care, deemed necessary to help me/ my child. I give the staff of the SCRUBS CAMP program permission to give medication to me/ my son/daughter on my behalf. I agree to pay for any prescribed medication or treatment I/ my son/daughter may need.

______/______/______

SIGNATURE OF SCRUBS CAMP PARTICIPANT DATE

______/______/______

SIGNATURE OF PARENT / GUARDIAN DATE

STUDENT EXPECTATIONS

Participants of the Minnesota SCRUBS Camp (SCRUBS CAMP)must agree to:

1. Bring only those items approved by the camp directors and to leave home those things which are neither appropriate nor allowed by the camp, includingelectronic entertainment including items such as MP3 players and computer games.
2. Refrain from smoking, drinking alcohol, and taking drugs other than those prescribed by my doctor.
3. Respect the authority of the camp staff by following their directions and accepting their decisions.
4. Respect University of Minnesota—Morris property.
5. Respect the needs and feelings of others, to show kindness to all that I comeinto contact with, and to help out whenever I can.
6. Refrain from any and all inappropriate language, gesturing, and behaviors.
7. Refrain from any and all violence, including physically or verbally abusing myfellow campers, bullying, fighting, harassing, yelling, and in general losing my temper.
8. Leave at home any items which are weapons or weapon-like.
9. Seek a peaceful resolution to all harsh words, threats, taunts, insults, and attacks and not return like for like, or “eye for an eye.” Peaceful resolution includes, but is not limited to, seeking the help of camp staff or simply walking away from the situation.
10. Respect the views, opinions, and beliefs of my fellow campers and camp staff, even if I do not agree with them.
11. If transportation assistance is needed at camp, I will contact a SCRUBS CAMP Coordinator at least 2 weeks prior to camp.
12. Stay together with the SCRUBS CAMP staff and students.
13. Pursue the fun and enjoyment of this camp experience whole-heartedly.
14. Follow my local school district’s policies including the dress code policy.
15. Follow-up meetings/emails with a SCRUBS CAMP representative to discuss my career development plan.

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

I have read and understood the requirements stated above and that I will be asked to leave the camp if my behavior threatens other camp participants’ and staff members’ safety or enjoyment. I understand that daily attendanceand appropriate behavior is required and is expected of me.

______/______/______

Signature of Applicant Date

______/______/______

Signature of Parent/Guardian Date

PHOTO RELEASE

I agree and consent that I/ my son/daughter may be photographedfor publicity purposes while participating in the MN SCRUBS Camp Program.

______/______/______

Signature of Applicant Date

______/______/______

Signature of Parent/Guardian Date

CAMP TRIP RELEASE

While he/she is in the MN SCRUBS Camp(SCRUBS CAMP) program, I agree and consent that on occasion my son/daughter may leave theproperty if so authorized by the SCRUBS CAMPcoordinator or person(s) in charge. This authorization shall continue to bein effect as long as my son/daughter is a SCRUBS CAMP participant.

______/______/______

Signature of Parent/Guardian Date

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