For students in Acadia, Allen, Lafayette, and Vermilion Parishes

LSUHSC School of Medicine –New Orleans

Southwest LA Area Health Education Center (SWLAHEC)

Invite you to apply for Day With The Docs

Thursday, November 10, 2016

Day with the Docs is a one-day interactive program that offers high school students who are considering becoming a doctor an opportunity to experience medical students’ daily activities and life on the LSUHSC School of Medicine campus in New Orleans. The planned activities are scheduled from 9:00 am to 4:00 pm. Students are transported to LSUHSC by school bus or other approved transportation. Lunch and morning/afternoon snacks are provided, and there is no other cost to the student except for spending money for a possible food stop during the trip home or a possible visit to the bookstore.

gross anatomy demonstration

physical diagnosis skills

case study of a patient

use of simulators

emergency care

life of a medical student panel discussion

tour of the medical school facility

interaction with medical students

Who can participate in Day With The Docs?

High school sophomores, juniors or seniors in Acadia, Allen, Lafayette, &Vermilion Parishes with a 3.0 GPA or higher, who are interested in becoming a doctor, may apply.

How do I apply?

You must complete an application and all required forms and then email or fax them toSWLAHEC,Attn: Brooke Voorhies. The application and all other forms are available from your school counselor or by going online to and clicking on forms. All applications and accompanying forms must be received in the SWLAHEC Lafayette office no later than Friday, September 16th, 2016. The following must be included:

  • Completed application which must include:
  1. parent permission form
  2. permission to retain information
  3. LSU consent for photography, interview, and recording
  4. emergency information/authorization for treatment form
  • 1 completed Teacher Recommendation Form from one of your high school scienceteachers
  • A copy of your transcript signed by a school official

Parishes are invited each year on a rotating basis. Due to space limitations, not all students in the invited parishes can be accommodated. Student selection will be based on GPA, answers to essay questions on the application, previous participation in health-related programs and teacher recommendation(s). Students who are selected will be notified by email and/or via their school counselor no later than September 30th, 2016. Questions may be directed to Brooke Voorhies at 337-989-0001 or by e-mail at .

Only use blue or black ink. Pink, purple, green, etc. are not acceptable. DO NOT write in pencil.

Do not change pens in the middle of an application. This looks unprofessional and doesn’t flow.

Take your time. Give plenty of thought regarding what you want to say before you write it.

Don’t fill outan application the last minute before a deadline.

Type in your answers unless the instructions say to hand write them.

When hand-writing an application, use your BEST penmanship.

Make sure your handwriting is legible. If it is hard to read, then type it. Ask an adult to look at it to help you determine if you should type it.

Read your answers out loud to yourself, then to someone else. Make sure that person will be honest with you about how it sounds.

Always have at least one other person proof-read your document.It’s a good idea to have that person be an adult who will be honest with you regarding mistakes or how it sounds, and will give you constructive criticism. (teacher, parent, etc.)

Do nothave your parents or others fill it out; there are always telltale signs that they did it.

Don’t draw pictures or dot the I’s with circles or hearts. You’re writing to a professional, not a BFF.

Do not leave blank spaces—at least write N/A (not applicable).

Check your spelling. Spelling errors are UNACCEPTABLE!

Make sure to use correct forms of words. Grammar is so important! Sound smart!

Do not write like you are sending a text message. Write words out, do not abbreviate.

In essay answers, do not ramble. Be honest and tell the facts. Get to the point but sell yourself.

When answering essay questions write it on another paper first, read it, proof it, then copy your answers onto the final draft. Again, have another person proof your final copy.

When asked to tell something unique about yourself, be specific …what makes you who you are? Tell about a talent, do you run marathons, speak 4 languages, have an interesting hobby, personally know a movie star? The question is prompting you to tell who you are.

“I’m a people person” or “I like helping people” is not unique.

Do not type an answer on another sheet then cut it and tape or glue it onto the application. It is better to type the questions and answers on a separate sheet if you choose, and then submit that sheet. If you choose to complete an application this way make sure to write after that question, see attached.

Do not ask your parents to call or email about an application if you have questions. You need to do this because you are the one applying.

Let your personality come through, while sounding professional!

DON’T FORGET TO SIGN IT! Details matter.

Day with the Docs

2016 Application

Event Date: Thursday, November 10, 2016

For students inAcadia, Allen, Lafayette and VermilionParishes

All forms are also available online at on forms on the homepage.

This application is to be completed by the student and must be returned to SWLAHECNo later thanSeptember 16th,2016

Legal Name______School______

Address______Parish______

(Where you attend school)

City, State, Zip______Circle year in school 10 11 12

Home Phone______Gender (circle one) Male Female

Student Cell Phone______Age ______

Student E-mail address______

(Please print clearly)

Ethnicity (check one; optional--- for Federal Reporting purposes): ______Hispanic/Latino

______Non-Hispanic/Non-Latino

Race (check one; optional—for Federal Reporting purposes)

_____ American Indian or Alaskan Native _____ African American

_____ Native Hawaiian or other Pacific Islander _____ Caucasian

_____ Asian (Chinese, Filipino, Japanese, _____ Other (not listed)

Korean, Asian Indian, Thai)

Do you have any food allergies? ______

Please circle your T-shirt size: s m l XL xxl xxxl

Parent/Guardian Name______Day Phone ______

Parent/Guardian Name______ Day Phone______

Have you attended any other AHEC programs? Yes _____ Name of Programs ______

No ______

Are you a member of HOSA-Future Health Professionals? _____Yes _____No

How did you hear about this program? ______

Which specific medical profession are you interested in?______

Please list allhigh school SCIENCEclasses you have taken or in which you are currentlyenrolled:

______

______

Page 1

  1. Are any members of your family employed in healthcare professions? If yes, please explain.

______

______

  1. Has anyone influenced your desire to enter a healthcare profession? Explain:

______

  1. Have you ever worked in a healthcare facility as an employee or volunteer? If yes, please explain where, when, and any training you received. (Donot include AHEC of a Summer)

______

  1. Have you ever participated in community service? Please list/explain.(Ex: blood drive,peer tutoring/mentoring, charity fundraising)

______
______

  1. Are you currently CPR certified?No______Yes ______
  2. Tell us something unique about you (Ex: I can recite all 44 U.S. Presidents in 30 seconds! I speak 4 languages, etc.)

______

I have answered all of the information on this application truthfully and to the best of my knowledge.

Student Signature______Date______

As the parent/guardian of the aforementioned student, I have read the information page regarding Day With The Docs and fully understand what participation involves.I also give permission for my child’s photo and name to be used in future press releases to local newspapers and on SWLAHEC’s web site and print materials.

Parent/Guardian Signature______Date______

Print Student Name______

Parish Where Student Resides ______

Applications MUSTbe received in the SWLAHEC Lafayette office byFriday, September 16th2016.Email or fax your signed application, a copy of your latestOFFICIAL transcript with GPA, completed Teacher Recommendation Form, and the permission formsto: SWLAHEC, Attn: Brooke Voorhies, Fax #337-989-1401, Email:

Failure to include all of the necessary forms, information, and signatures will exclude the applicant from being considered for the program. Teacher Recommendation Forms should be mailed in separately. If Recommendation Form is included with student application it must be in a sealed and signed envelope.

To clarify the day, you will not be shadowing doctors & will not view cadavers. You will be interacting with medical students, touring the facility, and finding out about life as a medical student. Part of the day will be in a lecture & question/answer forum. The remainder of the day will be hands-on or tours.

Page 2

ESSAY QUESTIONS

Student Name: ______

Your answers may be typed directly onto the form, typed on a separate sheet, or printedneatlyby hand. Each essay question should be answered with five to ten sentences. These questions are EXTREMELY important in our applicant selection process.

  1. What experiences have most motivated you to pursue the medical field?

______

2. How can you be sure that medicine is the right career for you? Convince me that you would make a good doctor.

______

Page 3

Emergency Information/Authorization for Medical Treatment Form

For 2016Day With The Docs

Student Name______Date of Birth ______

Address ______

City, State, Zip ______Home Phone ______Cell Phone ______

Parent Name ______Parent Phone______Work Phone ______Cell Phone ______

Parent Name ______Parent Phone______

Work Phone ______Cell Phone ______

Insurance Company______Policy Number______

Insurance Company Phone ______Name of Insured ______

Emergency Contacts

1. Name ______Relationship ______

Work Phone______Home Phone ______

Cell Phone ______

2. Name ______Relationship______

Work Phone______Home Phone______

Cell Phone ______

3. Name ______Relationship ______

Work Phone______Home Phone______

Cell Phone______

Medical Information: (Check only if condition is present or recurring.)

_____ Diabetes_____ Asthma_____ Heart Condition

_____ Hemophiliac_____ Hearing Aid_____ Wears Glasses/Contacts

_____ Neuro/Muscular Problem_____ Allergy_____ Other ______

If any are checked, please explain ______

Is the student on any type of medication? _____ yes _____ no

If yes, what is the medication and dosage? ______

If yes, may the student self-medicate? _____ yes _____ no

In case of a serious illness or injury, I hereby authorize hospital officials to make whatever arrangements are necessary and to contact me immediately. I understand that it remains my responsibility to make any changes in the information on this medical form should they occur between this date and November 10, 2016 by contactingBrooke Voorhies at Southwest Louisiana AHEC (337-989-0001). Otherwise, this authorization will remain in effect as it appears this date through November 10, 2016. I understand that neither Southwest Louisiana AHEC nor LSU Health Sciences Center – New Orleans nor the School District assumes responsibility for medical charges. Any medical charges will be the responsibility of the parent/guardian.

Parent/Guardian Signature ______Date ______

Daytime phone number ______

Teacher Recommendation Form

For 2016Day with the Docs

(This form is available on-line at Click on forms)

Name of Student: ______

Print Teacher Name: ______School:______

Name of your class:______Overall GPAinyour class:______

We understand that no one is perfect, so please honestlyrate the following traits on a scale of 1-5, using the scale below:

(5= little or no improvement needed; 4= Excellent; 3= above average; 2= average; 1= below average)

Work ethic _____ Initiative _____ Honesty _____

Dedication _____ Self-discipline _____ Attitude _____

Punctuality _____ Communication Skills _____ Sincerity _____

Teamwork _____ Maturity _____ Participation _____

(Your detailed comments below are VERY important in the applicant selection process.)

Does this student have any outstanding accomplishments orare you aware of any particular challenges that he/she has overcome that might be of interest to the selection committee? ______

______

______

______

Why do you feel this particular student will benefit from this program? ______

______

______

Other comments:______

Teacher’s Signature:______Date:______

(Please mail, fax, or email this form by September 16th, 2016)

Permission to Retain Information

To the parent(s)/Guardian(s) of the Day With The Docs program applicant:

During the 2014 Louisiana Legislative Session, the State of Louisiana enacted new laws governing the collection, disclosure and use of students’ personally identifiable information. Southwest Louisiana Area Health Education Center (SWLAHEC) has in place appropriate measures to ensure the confidentiality and security of personally identifiable information, protect against any unanticipated access or disclosure of information, and prevent any other action that could result in substantial harm to any individual identified by the data. The law also states that SWLAHEC must destroy, erase, or return to the School Board in a useable electronic format at the end of the contract, any identifiable information.

To measure the success of SWLAHEC’s high school programs, it is important to follow up with students over the course of several years, to find out if the student subsequently enrolled in health professions education or is employed in a health-related field. For the sole purpose of this follow-up, we are asking your permission to retain your student’s contact information so that we may conduct such a follow-up. We will only keep the information of students accepted into the program. The applications of those not accepted will be shredded.

The following information is retained by SWLAHEC: Name, Address, Phone, Email, School, Parish

Please complete and sign this form.

_____ I agree that SWLAHEC may retain my student’s contact information in a secure environment to be

used only for the purposes of follow-up.

_____ I do not agree that SWLAHEC may retain my student’s information in a secure environment to be

used only for the purposes of follow-up.

______

Print Name of studentParish

______

Print Parent/Guardian Name

______

Parent/Guardian signatureDate

Note: Following the completion of the program, all written personal information (application, transcript, medical information, etc.) will be shredded. Only the information listed above will be kept securely, with your permission. If your student is not accepted into the program, their information will be shredded.

CONSENT FOR PHOTOGRAPHY, INTERVIEW, RECORDING

I, ______, hereby grant permission to

LSU Health Sciences Center New Orleans to photograph, video tape,

record, or interview me, or in the case of a minor, my

child______, for print, broadcast, or

social media use, for use in LSU Health Sciences Center New Orleans

publications, video or audio tapes, brochures, website, or for use in

teaching by LSU Health Sciences Center New Orleans faculty.

I hereby transfer to LSU Health Sciences Center New Orleans all rights

and claims I have, or in the future may acquire, with respect to such

photographs, video recordings, audio recordings, and/or written materials,

agreeing that same shall be the sole and absolute property of LSU Health

Sciences Center New Orleans. I hereby relieve and release LSU Health

Sciences Center New Orleans from any and all claims whatsoever, and for

any and all kinds of remuneration for use of such materials.

Signature: ______Date: ______

Address:

______

______

______

Parent/Guardian PermissionForm

If chosen, I give permission for my child, ______, to participate and be transported by our School System or other approved transportation to and from the LSUHSC School of Medicine in New Orleans for the Day with the Docs program on Thursday, November 10, 2016.

I understand that if accepted my child and I will be notified of the time/location for departure and return.

I also give permission for my child’s photo and name to be used in future press releases to local newspapers and on SWLAHEC’s web site and print materials.

Parents/Guardians Names: 1. ______2. ______

Daytime Phone: ______

Cell Phone: ______

Home Phone: ______

Other Emergency Contact:

Name: ______Daytime Phone: ______

Relationship:______Evening Phone: ______

Cell Phone: ______

I certify that the information described above and on the Medical Information Form is accurate and complete to the best of my knowledge. I understand that each individual is responsible for his/her own insurance coverage during this trip. I hereby release the Southwest Louisiana Area Health Education Center, its Board of Directors and employees, the LSU School of Medicine, and any designated individual in charge of the Day With The Docs group or specific activity from any legal or financial responsibility with respect to my student/child’s participation in or contact with any known element associated with an activity during this event.

______

Parent/Guardian SignatureDate

This form must be returned with application

NO LATER THAN Friday, September 16, 2016