MEDEX ACADEMY Undergraduate Application

Transcription

1 Undergraduate Application Personal Information: Name: (Last) (First) (Middle) Preferred Name: Address: (Street) (Apt. Number) (City) (State) (Zip Code) Telephone: (Home) (Cell) (Other) Date of Birth: Gender: Male Female Citizenship: If not U.S., visa type: State Residence (What State do you call home?): Race/Ethnicity: White or Caucasian Black or African American Latino or Hispanic Asian Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Other Will you have summer housing accommodations? Yes No Enter initials acknowledging that you understand summer housing will not be provided. Initials: How did you hear about the MedEx Academy? Have you participated in the Medical Explorers program? Yes No If Yes, when and where did you participate in this program? Have you participated in any Upstate AHEC Health career programs? Yes No If Yes, when and where did you participate in this program?

2 Application Continued How many hours have you volunteered in a hospital or other medical establishment? None 10 Hours or Less 20 Hours or Less 30 Hours or Less 40 Hours or Less 50 Hours or Less More than 50 Hours Do you have any limiting conditions that should be considered for the purpose of accommodating your needs: Yes No If yes, please explain: In order to match participants with appropriate mentors, please list 3 health care areas in which you are interested. (1) (2) (3) Educational Background/Goals Information: Transcripts must be submitted prior to the application deadline to Al Squire, Director of Workforce Development, 701 Grove Road, Greenville, SC I understand my application is not complete unless my transcript is received by Al Squire prior to the application deadline. College/University: City: State: Current Classification: o Soph. o Jr. o Sr. Current cumulative GPA: Expected Graduation (month and year): List any relevant scholarships, awards & honors: List courses in which you are currently enrolled (note any lab courses):

3 Application Continued List any extracurricular activities (inside and outside of school) that you are involved in. List any community service activities you have been involved in: List any job experience you have (include dates, avg hrs/wk & responsibilities: Please check the appropriate box for your level of knowledge in the following areas: None Basic Intermediate Advanced MS Word MS Excel MS PowerPoint Do you have access to a laptop/computer at home? Yes No Do you have access to the internet at home? Yes No List any other technical skills that you have:

4 Application Continued Recommendations: Note: Two letters of recommendation are required. (Reference forms attached) At least one letter should be from a faculty member at your school. Reference #1: (Name) (Relationship) (School) (Address) (City) (State) (Zip Code) (Phone Number) ( Address) Reference #2: (Name) (Relationship) (School) (Address) (City) (State) (Zip Code) (Phone Number) ( Address) Essay: Note: An essay response is required for this application to be complete. The essay should be typed responses to the following questions: (Limit to no more than 300 words) Please describe your interests and personal thoughts about a future career in health care. Include your career goal(s). What do you hope to gain from the MedEx Academy experience? What contribution can you make to the MedEx Academy? Acknowledgement: I acknowledge that all of the information submitted in this application is correct and complete. Signature Date

5 Dress Code/Grooming Guidelines: Participants are expected to dress in an appropriate manner while working at GHS. Personal appearance shall support patient care, create a healthy and safe environment, and not offend patients, visitors, employees, or other participants. Identification Badges: Worn with picture and name visible Worn above the waist for easy identification Clear of clutter (pins, stickers, etc.) Clothing and Uniforms: Jewelry: Should be clean, neat and follow hospital guidelines Men: Shirt and ties for field experiences and business casual (shirt and khakis) for classroom experiences are the preferred attire. Ladies: Professional attire (dresses, pants, etc.) for field experiences. Business casual for classroom experiences are the preferred attire. Hats, scarves, hair curlers or other headwear may not be worn, unless required for infection control purposes The following list is NOT permitted while participating in MedEx Academy: o shorts, skorts, tank tops, T-shirts, jeans, halter tops, midriff shirts, leggings, warm up suits, crop, capri, and gaucho pants o tight fitting clothing o excessively baggy trousers and other clothing are not permitted o Clothing may not drag on the floor. o Clothes that inappropriately expose body parts or underclothing are not permitted. o clothes with messages o open-toed shoes, flip flops or sandals o visible tattoos Do not wear large earrings and long hanging jewelry No pierced ornaments should be visible except in ear Ears should not exceed two piercings per ear Jewelry should be kept to a minimum o No more than two rings per hand o Only appropriate and professional jewelry may be worn o Facial jewelry may only be worn on the ears unless for bona fide religious reasons. No more than three earrings per ear will be considered appropriate. o Tongue and dental jewelry is not permitted.

6 Hair, Fingernails and Perfume: Hair should be clean, neat, and trimmed. Mustache should be clean, neat, and trimmed. Hair color and contact lenses must be consistent with colors occurring naturally in humans Nail coloring, lipstick, and other make-up must be consistent with the expected appearance of a healthcare professional. Fingernails should not prevent a job from being done efficiently, safely, or with proper hygiene. Excessively long fingernails (artificial or real) shall not be allowed. Artificial nails or nail polish is discouraged in direct patient care areas, and when worn, should not be chipped or peeling. Perfume or other strong smelling scents should not be worn. Students must follow any other department specific guidelines as applicable. Entering my name here serves as my electronic signature acknowledging that I have read and agree to adhere to the Dress Code/Grooming Guidelines for MedEx Academy. I understand that if I do not adhere to these guidelines, I may be excused from my activities with the MedEx Academy. Signature Date