ACADEMY OF HEALTH SCIENCE APPLICATION

Dillard High School 2501 Northwest 11 Street  Fort Lauderdale, FL 33311

Telephone: 754-322-0876 Fax: 754-322-0930E-mail:

Name: ______

Street Address: ______

City, State, Zip: ______

Telephone: ______Date of Birth: ______Student ID #______

Student E-mail Address: ______

Parent E-mail Address: ______

Previous/Current work experience if any (briefly describe where/responsibilities):

______

Volunteer experience (briefly describe where/activities):

______

How many days were you absent last year? If more than 5, please explain.

______

List club memberships and extra-curricular activities:

______

ACADEMY OF HEALTH SCIENCE APPLICATION

TEACHER RECOMMENDATION

Dillard High School 2501 Northwest 11 Street  Fort Lauderdale, FL 33311

Telephone: 754-322-0876 Fax: 754-322-0930 E-mail:

List any enriched or honors courses you have taken:

______

List the name of math, English, and social studies courses you have completed:

______

Which foreign language(s) have you taken? (Indicate level of proficiency)

______

What is your overall grade point average (GPA)? ______

Registration Process

Request a current teacher to complete and turn in the recommendation form (teacher will turn form in independently of student’s application)

Key a two or three paragraph summary describing why you are interested in the Academy of Health Science and attach it to your application.

Application, Teacher Recommendation and Personal Summary Paragraphs

The AOHS team at Dillard High School will review all applications as part of the selection process.

Students will be notified of acceptance by email or telephone.

I understand that if I am accepted into this program, I am expected to be a full-time participant. I also know that a paid/unpaid summer internship between the junior and senior year of high school is one of the requirements for completion of AOHS. My acceptance further commits me to be a program participant through my senior year of high school. I am interested in being a student inAOHS.

Student signature/date: ______

Parent signature/date: ______

Student Name: ______

Please rate (circle the number) the student in the following categories: 5 is excellent, 3 average, and 1 is below average.

Academically on grade level / 1 / 2 / 3 / 4 / 5
Works well within a team / 1 / 2 / 3 / 4 / 5
Self-motivated / 1 / 2 / 3 / 4 / 5
Responsible / 1 / 2 / 3 / 4 / 5
Organized / 1 / 2 / 3 / 4 / 5
Integrity/trustworthiness / 1 / 2 / 3 / 4 / 5
Oral communication skills / 1 / 2 / 3 / 4 / 5
Work ethic / 1 / 2 / 3 / 4 / 5
Leadership potential / 1 / 2 / 3 / 4 / 5

Comments: ______

Please check one:

_____The applicant has my highest recommendation

_____ I recommend the applicant with confidence

_____ I recommend the applicant with some reservations

_____ I do not recommend the applicant

Teacher Name (please print): ______

Teacher Signature: ______

Subject: ______