Summer Academy

Application

I _________________________________________ am recommending ____________________________________________

(Teacher’s Name) (Student’s Name)

for participation in the ___________________ Healthcare Careers Summer Academy.

(Year)

This student fulfills the following criteria (check all that apply):

o High potential, not necessarily reflected in GPA

o Socio-economically disadvantaged

o Can add diversity to the workplace

o Bilingual—Competent in English & fluent in another language other than English

o Entering junior year

o Entering senior year

o Interested in science and math

o Other (please specify)

Subject Taught: o Biology o ESL o Other (please specify—program approval required)

Teacher’s Phone:________________________________________________________________________________________

School’s Address:________________________________________________________________________________________

Please make a brief statement regarding the reasons you have nominated this student:

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Mailing Address:________________________________________________ City:____________________ Zip:_____________

Home Phone:____________________ Cell Phone:____________________ Email Address: ________________________________

High School:_____________________________________________ Current cumulative GPA (please provide transcript):_____________

Grade level now: ________________ Grade level next fall:________________

Ethnicity:

o African American o Asian o Caucasian o Latino/a

o Native American o Pacific Islander o Other o Prefer not to respond

What language(s) are spoken in your home?_______________________________________________________________________

Are you fluent in a language other than English? o Yes o No

What language(s) are your fluent in?___________________________________________________________________________

Have you completed Biology? o Yes o No

If no, are you currently enrolled in Biology with a passing grade? o Yes o No

Parent/Guardian Name(s):__________________________________________________________________________________

Parent/Guardian Daytime Phone Number:_________________________________________________________________________

Parent/Guardian E-Mail (optional):_____________________________________________________________________________

The Healthcare Careers Summer Academy will provide a T-shirt for use during the Academy. Please specify what size you will need:

o Small o Medium o Large o Extra Large o XXL

1. How did you hear about HCSA? Why are you applying? What interests you most about HCSA?

2. Successful participation in the HCSA will require a commitment of three days a week for five weeks. Can you make that commitment? What might prevent you from completing the program?

3. What hobbies and extracurricular activities do you enjoy?

4. What kind of career or job do you see yourself having in the future? Why are you interested in that field?

5. If your friends were here now, and you were not in the room, how would they describe you?

6. How can you contribute to the cultural diversity in the healthcare workforce?

7. Please list any honors or awards you have received.

Signature of Applicant:________________________________________________ Date:________________________________

I, _____________________________________, am the parent/guardian for student ____________________________. I understand that my child is applying for the Healthcare Careers Summer Academy, which provides him/her with college/high school credit upon successful completion. I am aware that this program runs for five weeks and my child will be attending the program for three days a week for approximately five hours a day. I also am aware that this program will involve field trips off campus. If my child is chosen as a participant in the Healthcare Careers Summer Academy, I will demonstrate my support by assuring that my child:

• Has access to reliable transportation to the various places where activities will take place.

• Will arrive on time, appropriately dressed, equipped, and ready to actively participate.

• Will be provided an appropriate place to complete reading and homework assignments outside of class.

• Is aware that this program takes place on the campus of Sacramento City College. Like any typical college campus, it has students of adult ages, cigarettes and materials designed for adult reading/viewing for sale in its campus bookstore. Students involved with HCSA are not permitted to buy, use, sell, or possess cigarettes, alcoholic beverages, controlled substance, or adult reading materials. Failure to comply with this prohibition or with the direction of the program is grounds for removal from the program.

Parent/Guardian Signature:_____________________________________________ Date:________________________

In an emergency, when we cannot reach you at your daytime phone number, please list two people who have agreed to take responsibility for your student and have consented to the release of their address and phone so we may reach them as an alternative.

Contact:______________________________ Relationship:__________________ Phone:_______________________

Contact:______________________________ Relationship:__________________ Phone:_______________________

If deemed necessary, your student will be sent to your family doctor or emergency room at parent’s/guardian’s expense.

As parent/guardian, I authorize medical personnel to render necessary medical treatment to my student.

Parent/Guardian Signature:_____________________________________________ Date:________________________

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Summer Academy

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How to apply

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Screening and Interviews

March 15 – April 15

Final Selection Announced

Mandatory Orientation

Early June

Program Begins

1. A teacher nominates students by filling out the Teacher Nomination page on the application.

2. A teacher gives the application to the student and the student completes:

3. Obtain a copy of your high school transcript and include with your application.

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