Health Care Academy Application

Application Form
Health Care Career Exploration

Tuesday June 17, 2008
(8:00AM - 12:30PM)

Thursday June 19, 2008
(8:00AM - 12:30PM)

Please note that applications are taken on a first come first served basis and limited number of seats are available,
so if you have friends you would like to have apply - be sure and let them know .

	First Name:
	Middle Initial:
	Last Name:

	Mailing Address:
	City:
	State:
	Zip Code:

	Daytime Phone Number:

	What high school will you be attending in the Fall 2008-09 school year?		DHS FTHS MGHS PHS SHS THS Other (please specify)

	Which Date would you like to attend the Health Care Academy?		(Section Full)Tues June 17, 2008 (8AM-12:30PM) Thur June 19, 2008 (8AM-12:30PM)

	On the tour of the hospital's lab, does your parent / guardian give permission to have your blood type tested, and would you like to have this test done?		Yes No

	On the tour of the hospital, does your parent/guardian give permission for us to video tape and or photograph you to promote future GIFT programs?		Yes No

	I am most interested in the following area in the health care field::		Doctor Nurse Lab Tech X-Ray / Radiology Pharmacy Physical Therapy Certified Nursing Assistant Medical Record Keeping Other (please specify)