NORTHERN TIER INDUSTRY& EDUCATION CONSORTIUM

SUMMER HEALTHCARE PROGRAM APPLICATION FORM (Please print clearly) Student’s Name: Address:

Telephone: Date of Birth:

Street City

State

Zip

Male

Email: Female

Name of school district the student resides in: In the Fall of 2017, the student will be entering what grade? Circle the number beside the area(s) of Health Care you are interested in? 1. Emergency room 2. Operating room / surgery area 3. Nursing & patient areas 4. Lab /pharmacy 5. Radiology

6. Physical therapy / home health 7. Facilities (plant engineering/food service/housekeeping) 8. Administration (leadership/medical records/accounting) Other___________________________________

Does the student have any physical limitations that will prevent him/her from participating in this program? Does the student have any allergies?

Yes

No

If so, please list: Please list any medications: Mother’s Name:

Telephone:

Father’s Name:

Telephone: P.O. Box 200, Dimock, PA 18816 Phone (570) 278-5038, Fax (570) 278-2731

If applicable, Guardian’s Name:

Telephone:

Emergency Contact if above is unavailable:

Telephone:

Student’s Signature:

Date:

Parent’s Signature:

Date:

P.O. Box 200, Dimock, PA 18816 Phone (570) 278-5038, Fax (570) 278-2731