Johnston Memorial Hospital

Abingdon, Virginia

Middle School

Health Care Careers Day Camp

Application

Name ______Date ______

Address ______

Phone Number(s) ______

Emergency contact ______

School ______

Grade ______

Areas of interest:

  1. ______
  2. ______
  3. ______

Student Signature ______Date ______

Parent/Guardian Signature ______Date ______

Space is limited. You will be notified of acceptance by June 1, 2013.

Return completed application and consent form to:

Education Department

Johnston Memorial Hospital

16,000 Johnston Memorial Drive

Abingdon, VA 24211

Johnston Memorial Hospital

Health Care Careers Day Camp

Consent Form

Consent to Participate

I, the undersigned, in consideration of the benefit derived by the participation of the Day Camp do hereby release Johnston Memorial Hospital, its agents and staff from and against any and all liability and responsibilities for any injury, illness or sickness that may result from participation in this program.

I do understand that failure to follow the Dress Code Guidelines or Behavioral Expectations will cause the students dismissal from this program.

Medical Information

The staff of Johnston Memorial Hospital has my permission to seek emergency medical services for my child. If emergency medical services are needed, I understand that I am responsible for the expense.

Does your child have any medical conditions that we need to be aware of? Please list.

______

Allergies ______

Contact Information:

Father/guardian ______Mother/guardian ______

Phone Number ______Phone Number ______

Person to contact in case of an emergency if parents cannot be reached:
______

Media Permission

The hospital photographer may take photographs of activities throughout the week. In order for these photographs to be published, permission from the parents/guardian must be obtained.

You may have permission to have our child photographed during the day camp.

Student Name ______

Parent/guardian Signature ______

Date ______

Dress Code/Conduct Guidelines

Casual attire that includes comfortable clean walking shoes.

  • No strapless or low cut /cut off tops
  • No blue jeans
  • No shorts
  • No “mini” skirts
  • No open toed shoes
  • Long hair should by pulled back off the shoulders
  • Ear piercings only
  • No perfume or cologne because of patient sensitivity
  • Excessive jewelry should not be worn
  • No cell phones or other electrical equipment. A phone is available in the conference center if needed.
  • Lab coats may be required in some areas. These will be supplied by the hospital.
  • Offensive language is not allowed.
  • Treat everyone with respect.
  • Student will remain with their group at all times

* Failure to follow these guidelines may cause students dismissal from the program.