St. Mary s Health Professions Academy Student Application
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1 St. Mary s Health Professions Academy Student Application Tenth and eleventh grade students in tri-state area who are interested in a health care career will be considered for the St. Mary s Health Professions Academy. The Academy will be held on June 5 th and 6 th at the St. Mary s Center for Education. Only complete applications will be accepted. Applications must be received by May 1, Application Requirements Include: You must have at least a 2.5 or greater current overall grade average You must be a current high school student attending 10 th or 11 th grade I. STUDENT INFORMATION please type or print all responses legibly in ink Last Name First Name Middle Initial Nickname Birth Date (Month/Day/Year) Home Phone Cell Phone Address Mailing Address PO Box/Rural Route City State County Zip Code T-Shirt Adult Size : (p lease circle one ) Gender : Race : ( circle one or more ) XS (4/6) Male Caucasian S (6/7) American Indian/Alaskan Native M (8-10) Female African American L (12/14) Asian XL (16) Hispanic (non-caucasian) 2XL Pacific Islander 3 XL Mixed Race Medical Problems and/or Medications: How did you hear about St. Mary s Health Professions Academy? II. SCHOOL INFORMATION Name of School Currently Attending Current Grade in School School Address City State County Zip Code Phone (Including Area Code) 1
2 Current overall grade average (Must be at least 2.5 GPA) III. STUDENT AND PARENT SIGNATURES I certify that the information contained in this completed application is accurate. I understand that falsification of any information on this application may result in my being disqualified from the application process and/or the St. Mary s Health Professions Academy. If I am selected for the Academy and choose to participate, I agree to abide by all Academy rules and guidelines and participate in all of the scheduled activities. Student Signature Date I have read the application and certify that the information is accurate. I give my permission for my child to apply and participate in the St. Mary s Health Professions Academy. If my child is accepted and participates, I agree to support him/her throughout the program and will willingly respond as requested to the St. Mary s Health Professions Academy surveys regarding my child and his/her participation. I hereby agree that all participating entities will not be held responsible for any injury or accident that might occur through participation in the St. Mary s Health Professions Academy; in addition, any medical expenses incurred as a result of such injury or accident will be my personal responsibility. Parent/Guardian Signature Date In case of medical emergency, staff must be able to contact a parent/guardian or other emergency contact authorized to approve medical treatment for the student. Please provide current, accurate information and assure that you and/or a back-up contact are always available while the student is participating in Academy activities. Parent/GuardianName (print) Back-Up Contact Name (print) Address Relationship to Student Home Phone Cell Phone Work Phone Home Phone Cell Phone Work Phone Please Return Application to : For Questions and Concerns: Dr. Joey Trader, Ed.D., MSN, RN, CNE Paula Cremeans Vice President Schools of Nursing and Health Professions Administrative Secretary Director School of Nursing St. Mary s Center for Education St. Mary's Center for Education 2900 First Avenue 2900 First Avenue Huntington, WV Huntington, WV Office: Office: Fax: Completed Application Must Be Returned by May 1,
3 St. Mary s Health Professions Academy Health Assessment Form Instructions to Parent/Guardian : Please fill out your child s medical form and include it with the other forms to be returned to the Academy. Student s Name: DOB: HEALTH ASSESSMENT: Complete each line Yes No Comments Vision / Wears Corrective Lenses Hearing / Wears Hearing Aid Skin Disorder Special Nutritional Requirements Neurological Disorders (such as Epilepsy) Spinal Disorder Allergies (Medication, Food, Latex or Environmental) Digestive Disorder Muscular Disorder Asthma Heart Problems Tobacco Use Pregnant Chronic illness that may require medication or special accommodations? If yes, please explain: Parent Signature: Date: 3
4 Consent to Photograph Name: (please print) Last First Middle I hereby give consent to St. Mary s Medical Center to take moving and/or still photographs and/or sound/video recordings for any and all educational and/or marketing purposes that the hospital may deem proper of (check appropriate person): Son Daughter Other individual for whom I am authorized to provide consent Made on (date pictures taken): June 5 th and June 6 th, 2018 Used for: St. Mary s Center for Education I understand that these photographs and/or sound/video recordings will be used on behalf of St. Mary s Medical Center for the above stated purposes. I further relinquish all right, title and interest in said moving and/or still photographs and sound/video recordings. I also state that I have signed this form PRIOR to the taking of any photographs and/or sound/video recordings. Participant s Signature: Date: Parent s Signature: 4
5 St. Mary s Medical Center for Education 2900 First Ave Huntington, WV (304)
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