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

SUMMER HEALTHCARE PROGRAM - Application.pdf

There was a problem previewing this document. Retrying... Download. Connect more apps... Try one of the apps below to open or edit this item. SUMMER ...

63KB Sizes 0 Downloads 148 Views

Recommend Documents

SUMMER HEALTHCARE PROGRAM - Permission.pdf
SUMMER HEALTHCARE PROGRAM - Permission.pdf. SUMMER HEALTHCARE PROGRAM - Permission.pdf. Open. Extract. Open with. Sign In. Main menu.

711.4, SUMMER SCHOOL PROGRAM TRANSPORTATION ...
711.4, SUMMER SCHOOL PROGRAM TRANSPORTATION SERVICE.pdf. 711.4, SUMMER SCHOOL PROGRAM TRANSPORTATION SERVICE.pdf. Open.

Pegasus Theater Summer Program Application.pdf
850 Newman Springs Rd. Lincroft, NJ 07738 ... Pegasus Theater Summer Program Application.pdf. Pegasus Theater Summer Program Application.pdf. Open.

Pre-College Summer Program UNav.pdf
Page 2 of 4. B. R. I. E. F. P. RO. G. RAM. OV. E. RV. I. E. W. T. h. e. P. r. e. -. C. olle. g. e. P. r. o. g. r. a. m is. d. e. sig. n. e. d. f. o. r in. c. o. min. g. j. u. nio. r. s. a. n. d. s. e. nio. r. s in. t. e. r. e. s. t. e. d in. t. h. e

2017 FFTROCC Summer Music Science Program Description.pdf ...
2017 FFTROCC Summer Music Science Program Description.pdf. 2017 FFTROCC Summer Music Science Program Description.pdf. Open. Extract. Open with.

Summer Youth Track Program
Somers High School track , June 26 th through August 3 rd , 2017. Please make every ... Pre registration by mail (see form below) or online at www.runner.org or.

Summer Research Program Overview -
professors from top universities, civil services officers (IAS, IPS, IFS, IRS etc),it is important that interns exhibit highest level of professionalism in all aspects of their conduct during such interactions. Typically interns in the Program set am

What Works in Healthcare: Summer 2013 Special Issue - Esri
PAGE 7. Making a Case for Patient Engagement. Mohan Srireddy. PAGE 10. Q&A with the Experts ... TDWI is a trademark of 1105 Media, Inc. Other product and company ... We've also included one of our most popular Webinars from last year: Actionable ....

Summer Meals Program Sign Up (2).pdf
Whoops! There was a problem previewing this document. Retrying... Download ... Summer Meals Program Sign Up (2).pdf. Summer Meals Program Sign Up (2).

Madonna-House-Summer-Program - 2017.pdf
There was a problem loading this page. Retrying... Madonna-House-Summer-Program - 2017.pdf. Madonna-House-Summer-Program - 2017.pdf. Open. Extract.

Summer Program - Weekly Update July 17 2017.pdf
There was a problem loading this page. Retrying... Summer Program - Weekly Update July 17 2017.pdf. Summer Program - Weekly Update July 17 2017.pdf.

Mandala Group - On the Ground Summer Program - Apr 6.pdf ...
Mandala Group - On the Ground Summer Program - Apr 6.pdf. Mandala Group - On the Ground Summer Program - Apr 6.pdf. Open. Extract. Open with. Sign In.

Madonna-House-Summer-Program - 2017.pdf
Patrick Stewart. Whoops! There was a problem loading this page. Madonna-House-Summer-Program - 2017.pdf. Madonna-House-Summer-Program - 2017.pdf.