WestVirginiaJunior Nursing Academy

Acollaborative effort supportedby:

Student Application

Seventh andeight grade students in West Virginia who are interested in a nursing career will be consideredfor the WestVirginia Junior Nursing Academy. The Academy will be heldon DATEthrough DATE,atLOCATION andADDRESSOnly complete applications willbe accepted. Applicationsmust be received byDATE.

ApplicationRequirements Include:

•You must have at least an80% current overall grade average

•You must be a current middle school student attending7thor 8thgrade

•You must submit a brief essay (1 pagelimit) that explains your personal interest in the nursing profession and why attending the West Virginia Junior Nursing Academy isimportant to you. Youressay must besubmittedwith this application.

I. STUDENTINFORMATIONPleasetype or printallresponseslegiblyinink

LastNameFirstNameMiddleInitialNickname

BirthDate(Month/Day/Year)HomePhoneCellPhoneEmailAddress

StreetAddressPOBox/RuralRoute

CityStateofWestVirginiaCountyZipCode

Scrub Size(Pleasecircle one):

Adult XS (4/6) S (6/7) M (8-10) L (12/14) XL (16)

MedicalProblems and/or Medications:

II.SCHOOLINFORMATION

NameofSchoolCurrentlyAttendingCurrentGradeinSchool

SchoolAddressCityStateof WestVirginia

CountyZipCodePhone(IncludingAreaCode)

Currentoverallgradeaverage(Mustbeatleast80%)

CompletedApplicationMustBeReturnedbyDATE(oneweek)

III.INFORMATION TOBECOMPLETED BYSCHOOLCOUNSELORORTEACHER

SchoolCounselor/TeacherName(PRINT)TitlePhoneNumber

I certifythat the student applicant hasa currentoverallgrade averageof %. (Mustbe at least 80%)

SchoolCounselor/TeacherSignatureDate

IV.STUDENTANDPARENTSIGNATURES

I certifythat the informationcontainedinthiscompleted applicationisaccurate.Icertifythat I wrotethe essayI am submitting withthisapplication.I understandthatfalsificationof any informationonthisapplicationmay resultinmy beingdisqualified from the application processand/orthe WestVirginiaJuniorNursingAcademy.IfI am selectedforthe Academy and chooseto participate,Iagreeto abide byall Academyrulesandguidelinesand participate inallofthe scheduledactivities.

StudentSignatureDate

I have read the application andcertifythat the informationis accurate.Igivemypermissionformy childto apply andparticipate in the West VirginiaJuniorNursingAcademy. If my childisaccepted andparticipates,I agree to support him/herthroughoutthe program andwillwillinglyrespondas requested to the West VirginiaJuniorNursingAcademy surveysregarding my childandhis/herparticipation.I herebyagreethat allparticipatingentitieswillnot be heldresponsibleforany injuryoraccidentthat might occurthroughparticipationinthe WestVirginiaJuniorNursingAcademy; in addition, any medical expensesincurredas a resultof suchinjuryoraccident willbemypersonalresponsibility.

Parent/GuardianSignatureDate

I give my permissionforphotographs to betakenof me/my childto beusedinpublications,newspapers,television,websitesor other visualmedia as related to the West VirginiaJuniorNursingAcademyandall collaboratingagencies.I understandthat the above videotapes/photographs become theproperty of the WestVirginiaCenterfor Nursingand/orthe SPONSORINGAGENCYand thevideotapes/photographsmaybe usedfornews,educationorotherpurposesrelated to the advancement ofprofessional nursinginWestVirginia.

StudentSignatureDate

Parent/GuardianSignatureDate

In caseof medicalemergency,staffmustbeable to contacta parent/guardianor otheremergencycontactauthorizedto approve medicaltreatmentforthestudent.Pleaseprovidecurrent,accurateinformation andassurethat you and/oraback-upcontactare alwaysavailable whilethestudentisparticipating inAcademy activities.

Parent/GuardianName (PRINT)Back-up Contact Name (Print)

Address / Relationshipto student
HomePhone / CellPhone / WorkPhone / HomePhone / CellPhone / WorkPhone

Pleasereturn application to:For questions and concerns:

SPONSORINGAGENCYCONTACTNAME/ADDRESSSPONSORINGAGENCYCONTACTPHONENUMBER

CompletedApplicationMustBeReturnedbyDATE(oneweek)