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Student Application for Rural High School Medical "Camp"
June 21 - 26, 2009

 

Instructions: Applications are only accepted online. All questions must be answered, except where noted. Please send two letters of recommendation from adults not related to you and a current photo (school photo is acceptable). The photo should be a head shot, approximately 2” x 3” suitable for placement in your local newspaper should you be accepted into the program. Digital photographs are preferred and can be sent by email to sliger@etsu.edu. Standard photos can be mailed to : ETSU Department of Family Medicine, Attn: Carolyn Sliger, P.O. Box 70621, Johnson City, TN, 37614-1709.

 

1.  Student's Name (Last):

 

2.  Student's Name (First):

 

3.  Home Address:

 

4.  Home City:

 

5.  Home State:

 

6.  Home Zip:

 

7.  Age (must be 16 or older):

 

8.  Telephone # (include area code):

 

9.  E-mail (Required):

 

10.  Please give us permission to share your email address with the other participants.

Yes No

 

11.  Please give us permission to publish pictures taken during the 'Camp' that include you.

Yes No

 

12.  T-Shirt Size (Men's):

Small Medium Large Extra Large XX Large

 

13.  Race/Ethnicity (indicate all that apply):

American Indian Alaskan Native Asian Black or African American Native Hawaiian or other Pacific Islander White or Cauucasian Hispanic Latino

 

14.  Current Grade:

10'th 11'th 12'th

 

15.  As a high school student, would you say you make mostly:

Mostly A's Mostly B's Mostly C's Other

 

16.  School:

 

17.  Guidance Counselor:

 

18.  Guidance Counselor Telephone:

 

19.  School County:

 

20.  Guidance Counselor Fax:

 

21.  Guidance Counselor E-Mail Address:

 

22.  What is your GPA (grade point average)? Minimum 2.5 required.