dixie health career n.e.r.d. summer enrichment program ... · donation solicitation ... actual cost...
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2016 Dixie NERD Summer Enrichment Application (Application Deadline February 16, 2016) Page 1 of 1
2016 Dixie Health Career N.E.R.D. Summer Enrichment ProgramDixie Health Career N.E.R.D. Summer Camp Application
Students must be current high school students from West Central Alabama AHEC service areas to applyWest Central Alabama AHEC Service Counties: Lamar, Fayette, Pickens, Tuscaloosa, Greene, Hale, Sumter, Bibb, Perry, Marengo, Dallas, Wilcox, Choctaw
Applications must be received prior to February 16, 2016 to be considered. Please direct questions to and mail application to: 2014 Dixie Health Career N.E.R.D. Summer Enrichment Program
c/o West Central Alabama AHEC800 Hall St. Ste. C
Greensboro, AL 36744Tel: 205.886.6260 Alternate Phone: 205.614.6211
[email protected] complete application consists of the following:
Application Form Health Information Form / Declaration of Insurance Attached Copy of Insurance Card Liability Release Statement / Consent for Photography & Media use /Parent Permission $5 non‐refundable application fee – checks made payable to “West Central Alabama AHEC” (This fee is for processing of applications and will hold your place at camp if selected. Total cost of camp to student is $50, which includes all meals, activities, and uniforms during length of stay. If this $50 fee is a hardship for you and your family, please contact Alicia Logan at 205.886.6260 or [email protected] Solicitation Signature Form: Applicants must ask at least (5) community members to donate towards actual cost of camp, which is valued at $450, using the letter template included with application.
Dixie Health Career N.E.R.D. Summer Enrichment Program Description
Who: The Dixie Health Career Never Ending Road to Discovery (NERD) Summer Enrichment program is funded by the West Central Alabama AHEC (Area Health Education Center). West Central Alabama AHEC is organization whose aims are to improve the health of Alabama communities by developing a quality health workforce and addressing unmet health needs. One way we do this is by encouraging students to pursue careers in healthcare. What: Dixie Health Career NERD Summer Enrichment program is a week‐long health career exploration experience on the University of West Alabama campus (located in Livingston AL) designed to enrich the lives of students who show a genuine interest in learning about health professions. Through intensive and interactive activities and sessions, students will be provided with basic health skills training, educational growth, and invaluable resources. Our focus is on accepting students who come from disadvantaged or rural communities, or will be first in their family to attend college.When: June 6‐10,2016Why: Alabama, and the nation as a whole, is facing a healthcare workforce shortage. To develop the next generation of healthcare professionals, the West Central Alabama AHEC has created this program as one way to foster student’s interest in pursuing careers in healthcare.
2016 Dixie NERD Summer Enrichment Application (Application Deadline February 16, 2016) Page 2 of 1
2016 Dixie Health Career N.E.R.D. Summer Enrichment ProgramPERSONAL INFORMATION **Attach additional pages as needed, include your name on each page**
___ Check here if you are a student from a school without a HOSA program
1A. Have you applied to before, Yes or No? (circle one) Have you attended WCAA AHEC programs, Yes or No?
1. Last name: First:_________________________M. initial:________
2. Mailing address: Town State Zip code
3. Phone: ________________ Student E‐mail: ______________________Parent Email: ________________________ Please provide valid, legible, email addresses that will be checked regularly. This will be the method of communication from the WCAA staff.
4. WCA AHEC County(see 1st page): 5. Gender: [ ] Female [ ] Male
6. Birth date: 7. Current age:
8. High school presently attending: __________________________ City:_________________ Phone:_____________
9. Currently what grade are you in? 9th 10th 11th 12th Name of Guidance Counselor:_________________________
10. Do you plan to attend college? [ ] Yes [ ] 2 yrs. [ ] 4 yrs [ ] Other: _______________________________
[ ] No Other post‐graduation plans: _________________________________
11. How interested in a healthcare career are you? (circle one) Not at all Somewhat Very
12. How likely are you to pursue education in a healthcare field? Not at all Somewhat Very
13. Please list your top areas of career interest. i.e.: physician, radiologic technician, physical therapist, nurse, etc…
A. B. C.
14. Please list community service and/or volunteer activities you have participated in during high school.
15. Please list extracurricular activities (music, church, sports, etc.) in which you have been involved.
16. Please list any honors you have received while attending high school.
17. Please list any shadowing experience, noting facility information and total hours spent.
2016 Dixie NERD Summer Enrichment Application (Application Deadline February 16, 2016) Page 3 of 1
2016 Dixie Health Career N.E.R.D. Summer Enrichment Program
Health Information Form
Any current health problems/injuries/disabilities (physical or mental)?________________________________________
Any recreation restrictions?___________________________________________________________________________
Allergic reactions (food, insects, pollen, drugs, other)______________________________________________________
Any special dietary needs?____________________________________________________________________________
Name of family physician:______________________________________________ Telephone_____________________
Please list all prescription medications that the participant will bring to camp: ______________________________
Would you like the AHEC staff to store medication in a lock box for the participant? __________________________
Please list any non‐prescription medications the participant will use during camp: ___________________________
Primary Emergency Contact Information________________________________________________________________
Secondary Emergency Contact Information______________________________________________________________
Student Initial: _______ Parent Initial_______
Declaration of InsuranceHealth insurance is a necessity for every individual attending WCAA Summer Enrichment Camp. The West Central Alabama AHEC staff want to ensure that each student has medical insurance and access to healthcare should they need it in the event they are ill or in need of medical assistance. Please complete the following, check the line that applies, and return this form to us, along with other application materials, by February 16, 2016. Students without insurance will not be allowed to participate in Dixie Health Career NERD Summer Enrichment Camp. Please let us know if this requirement is a problem. Students may be able to be covered through Alabama ALL Kids (www.adph.org/allkids/ or 888.373.5437) or it is possible to arrange for short‐term health insurance. Medicaid is coverage.
Participant Name _______________________________________________________________
Name, address, and phone number of person responsible for participant’s medical bills.______________________________________________________________________________
______________________________________________________________________________
[ ] I have health insurance. My insurance company and policy numbers are listed below (please attach a copy of the insurance card):
_______________________________________________________________________
[ ] I do not have health insurance. I therefore understand that if I cannot arrange for coverage, temporary or otherwise, I will not be able to participate in the Dixie Health Career NERD Summer Enrichment Camp.
2016 Dixie NERD Summer Enrichment Application (Application Deadline February 16, 2016) Page 4 of 1
2016 Dixie Health Career N.E.R.D. Summer Enrichment ProgramSTUDENT BACKGROUND Please note: West Central Alabama AHEC does not discriminate based on information provided. However, preference is given to students who are from a rural background; are minorities; are disadvantaged; or who arel first generation college students. Travel will be provided to and from a central location to the University of West Alabama, but it will be the student’s/parent’s responsibility to get student to/from the central location.
18. What class does your high school fall into (ex: 5A,4A,3A,2A)_________________
19. A. Do you describe yourself as: ( ) Hispanic/Latino or ( ) Non‐Hispanic/Latino
B. How would you describe your racial origin? (Please check as many as apply)[ ] Asian [ ] American Indian/Alaskan Native (Tribe(s): ______________________________________________________)[ ] Black/African American[ ] Native Hawaiian/Pacific Islander[ ] White/Caucasian[ ] Other: ____________________________________________
20. Do you qualify for free or reduced lunch (even if you do not receive it) Yes / No (please circle one)
See income guidelines here: http://www.opi.mt.gov/pdf/SchoolFood/Forms/12_13EligibilityGuidelines.pdf
21. Please respond according to the parent(s)/guardian(s) with whom you live most of the time:Parent or Guardian #1 Parent or Guardian #2Name: Name:
Occupation: Occupation:
Previous Healthcare Employment: Yes /No Previous Healthcare Employment: Yes /No
Education: Education: (Highest level completed) (Highest level completed)
School (counselor, teacher, etc.)
Online (where?):___________________________
AHEC Staff Hospital: _________________________________
Flyer/Poster Other: ___________________________________
22. How did you hear about Dixie Health Career NERD Summer Enrichment Camp? (please check all that apply
2016 Dixie NERD Summer Enrichment Application (Application Deadline February 16, 2016) Page 5 of 1
2016 Dixie Health Career N.E.R.D. Summer Enrichment Program
Liability Release StatementIN CONSIDERATION of participation in the West Central Alabama AHEC camp, Student and Student’s Parent or Legal Guardian are hereinafter referred to as the “UNDERSIGNED.” The UNDERSIGNED hereby release the University of West Alabama and staff, West Central Alabama AHEC and its successors and assignees, from all claims for damages arising out of or related to any loss, damage, or injury incurred by Student or Student’s property which may occur during Student’s participation in the summer camp, whether arising directly or indirectly from such participation in said program. The UNDERSIGNED acknowledge the Health Information Form to be true to the best of their knowledge, and certify that there are no medical reasons to the best of their knowledge that would not allow the STUDENT to participate in any or all of the activities of the Dixie Health Career NERD Summer Enrichment Program. The UNDERSIGNED hereby state that no claim for negligence will be pursued against the University of West Alabama, West Central Alabama AHEC or the applicable university system in connection with any injury arising out of such participation in the Dixie Health Career NERD Summer Enrichment Program.Student Initial: _______ Parent Initial_______
The UNDERSIGNED understand that participants will be under adult supervision during the organized activities and while in the dormitory. It is also understood that participants will observe the University of West Alabama rules designed for student safety and will exhibit proper behavior. In the event of an injury or illness, the UNDERSIGNED consent that all necessary and/or appropriate treatment in connection with such injury/illness may be administered by qualified medical and/or dental personnel that are available in the area referred by the University of West Alabama staff. The UNDERSIGNED understand that this may be applicable in cases where parental contact is impossible or untimely.Student Initial: _______ Parent Initial_______
The UNDERSIGNED realize that participants will have the opportunity to participate in a variety of hands on activities (such as CPR certification, injection simulators, etc…) facilitated by the staff of healthcare facilities, colleges, and/or several different University departments. The UNDERSIGNED understand that participants have the option of choosing not to participate in any particular activity. Student Initial: _______ Parent Initial_______
Consent for Photography and Media UseDuring the Dixie Health Career NERD Summer Enrichment Camp, photographs and videotape footage may be taken for purposes of documenting the program, promoting the program, and evaluating the program. I hereby consent to be photographed during camp, with the understanding that photographs may be used for media use in AHEC‐related publications.____ yes ____ no
I additionally consent to being identified by name in connection with the publication of photographs.____ yes ____ no
Student Initial: _______ Parent Initial_______
I, _____________________________, hereby grant permission for my child, __________________________________, to participate in a 2016 Dixie Health Career NERD Summer Enrichment Camp. I CERTIFY THAT I FULLY UNDERSTAND THE ABOVE GUIDELINES AND THAT THE INFORMATION GIVEN IN THIS APPLICATION IS TRUE AND CORRECT. I understand that the West Central Alabama AHEC reserves the right to remove students from the summer program at any time for misconduct or non‐compliance with policies and procedures.Signature of applicant: Date:
Signature of parent/guardian: Date:
2016 Dixie NERD Summer Enrichment Application (Application Deadline February 16, 2016) Page 6 of 1
West Central AL AHEC Donation Request Letter
Dear Sir or Madam,
Engaging students in allied health careers is one of the most important factors in creating tomorrow’s workforce.
The West Central Alabama AHEC’s Dixie Health Career NERD (Never Ending Road to Discovery) Summer Enrichment Program is a program that addresses this issue. The Dixie Health Career NERD Summer Enrichment program is a week long health career exploration experience at the University of West Alabama campus designed to enrich the lives of students who show a genuine interest in learning about health professions. Through intensive and interactive activities and sessions, students will be provided with basic health skills training, educational growth, and invaluable resources. Our focus is on accepting students who come from disadvantaged or rural communities, or who will be the first in their family to attend college.
The Dixie Health Career NERD program will be offered to 13 counties (Lamar, Fayette, Pickens, Tuscaloosa, Greene, Hale, Sumter, Bibb, Perry, Marengo, Dallas, Wilcox, Choctaw) as a capstone summer experience relating to health career exploration activities that they have participated in with West Central Alabama AHEC during the school year. Participants are typically students in grades 9-12 that have expressed an interest in pursuing careers in healthcare. Camp is scheduled for June 6-10,2016.
West Central Alabama AHEC (Area Health Education Center) is a 501 (c) 3 organization whose aims are to improve the health of Alabama communities by developing a quality health workforce and addressing unmet health needs. One way we do this is by encouraging students to pursue careers in healthcare. We would like to request your assistance in providing this opportunity to the students of West Central Alabama. Your sponsorship, in any amount, would be greatly appreciated, and be used to cover costs such as transportation, food, uniforms, and activities. Actual cost of camp per student is $450, and students have been asked to contribute $50 towards costs.
If you have any questions or would like additional information about the mission and goals of West Central Alabama AHEC, please contact Regina Knox, Executive Director at (205) 614-6211 or Alicia Logan, Program Coordinator at (205) 886-6260. Send email inquiries to [email protected] or [email protected]. You may also visit www.wcaachec.org for more information.
Regards,
Alicia M. Logan, MSProgram Coordinator, West Central Alabama AHEC800 Hall St. Ste.C.Greensboro, AL 36744(205) 886-6260Cell (205) [email protected]
2016 Dixie NERD Summer Enrichment Application (Application Deadline February 16, 2016) Page 7 of 1
www.wcaahec.org
2016 Dixie NERD Summer Enrichment Application (Application Deadline February 16, 2016) Page 8 of 1
DONATION SOLICITATION SIGNATURE PAGEApplicant: Please ask at least (5) community members to donate towards the actual cost of camp, which is valued at $450.00. After they have reviewed the informational letter provided to you within the application, have them fill out the information below and return this page along with your completed application. Suggested partners: churches, youth groups, hospitals, schools, friends, and family members. Checks may be made payable to West Central AL AHEC and can be returned with your application. Questions may be directed to Alicia Logan, Program Coordinator at (205) 8866260 or [email protected]. Community Partner: Please complete the information below. West Central AL AHEC will only contact those who indicate that they would like to hear more about the programming that we offer youth and individuals within your county.
COMMUNITY PARTNER NAME
CONTACT INFORMATION
CONTRIBUTION AMOUNT & METHOD
WISH TO BE CONTACTED? Y OR N
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