2017
“AHEC of a Summer”
Health Careers Volunteer ProgramApplication
DEADLINE: March 10, 2017
Submit Completed Application By Mail to:
ATTN: Lydia Duval St. Mary Parish School Board
PO Box 170 Centerville, LA 70522
Note: Applications are available on-line at or applications are being distributed in each parish high school system personnel in the guidance office.
Applications must be filled out by the student in blue or black ink. Please print.
Name: ______Parish: ______Address: ______School:______
City, State, Zip: ______Current year in school: 9 10 11
Home Phone:(_____)______Gender: Male Female
Date of Birth: ______Age: ______
Student Email Address: ______
Please print clearly
Please note: HRSA requires that AHECs report data on race and ethnicity for federal statistics, program administrative reporting, and civil rights compliance.
Race (check those that apply)
_____ American Indian or Alaska Native
_____ Asian (Chinese, Filipino, Japanese, Korean, Asian Indian or Thai)
_____ Asian (Any Asian other than those listed above)
_____ Black or African American
_____ Native Hawaiian or Other Pacific Islander
_____ Caucasian
Ethnicity (check one)
_____ Hispanic or Latino(A person of Cuban, Mexican, Puerto Rican, South or Central
American, or other Spanish culture or origin)
_____Non-Hispanic
What isyour high school semester grade for Biology or General Science class?______
Do you have reliable transportation to the program site? Yes_____ No_____
Parent/Guardian Names ______
Parent/Guardian Addresses (if different from student’s)______
MotherFather
Parent/Guardian Work Phone ______
Parent/Guardian Home Phone ______
Parent/Guardian Cell Phone ______
Note: Acceptance into the “AHEC of a Summer” program requires a fee of $15 money order(FEE DUE AFTER RECEIVING ACCEPTANCE LETTER) and a commitment of approximately 90-100 total hours of weekday volunteer service at designated health care facilities between late May and early June. Volunteers do NOT receive wages or salary through the AHEC of a Summer program. Signing this application is an indication of your availability and commitment to participate in ALL scheduled “AHEC of a summer” activities. Fee is NOT to be sent with this application.
Applicant signature: ______Date: ______
Parent/guardian signature: ______Date: ______
Return the completed application to the person designated below:
Lydia Duval-AHEC CoordinatorSt. Mary Parish School Board PO Box 170 Centerville, LA 70522
This program is a cooperative service of the Southwest Louisiana Area Health Education Center, parish school boards, local hospitals, clinics, and other health care facilities and offices.
From time to time, students will be contacted by Southwest Louisiana AHEC as a follow-up to this experience.
List the name of all high school science classes which you have taken or are currently enrolled:
______
______
How did you learn about the “AHEC of a Summer” Health Careers Volunteer Program?
______
Are any members of your immediate family employed in a health care profession?
Yes ______No______
If yes, what profession? ______
Are you considering a career in health care? Yes ______No ______Possibly ______
If yes, what would you like to do? ______
Have you ever worked in a health care facility as a volunteer or employee? Yes____No____
If yes, where, when, andwhat was your job? ______
______
If you had a choice, which hospital department would you be most likely to volunteer in and why? Dietary Laboratory Emergency Room Occupational Therapy Other
Nursing Radiology Physical Therapy Health Information Management
List Site area of interest: ______
Uniform Size InformationNote: These are in unisex sizes, please choose accordingly. Keep in mind the uniform should be loose fitting. It is better to order a little too large than too small. The scrubs come in sets. We cannot make exchanges, or mix top and bottom sizes.
Size XS S M LG XL 2X 3X
Bust/chest 35-36 37-39 40-43 44-47 48-50 51-53 54-57
Waist 26-27 28-31 32-34 35-38 39-41 42-45 46-49
Hip 37-38 39-41 42-45 46-48 49-52 53-56 57-59
What size scrub set would you like? Top size: ______Pants size: ______
Would you like to order an additional set of scrubs? Yes_____ No_____
(One set will be provided at no charge to you. A second set is recommended as scrubs must be cleaned daily)
Cost: $15.00/setfor additional sets(Money Orders only made out to Southwest Louisiana AHEC of Summer Program)
Why do you wish to participate in the “AHEC of a Summer” Program and what do you hope to gain from the experience?
______
______
______
______
______
Have you ever participated in any volunteer, extracurricular, or community activities? Describe and tell us what you learned from those experiences.
______
______
______