MEDEX ACADEMY

High School Student Application

Name:______

(Last) (First) (Middle)

Preferred Name: ______

Address:______

(Street) (Apt. Number)

______

(City) (State) (Zip Code)

Telephone:______

(Home) (Cell) (Other)

E-mail: ______Date of Birth: ______Gender: □ Male □ Female

Citizenship:______If not U.S., visa type:__

State Residence (What State do you call home?):______

Will you have summer housing accommodations? Yes_____ No ______

Initial acknowledging that you understand that summer housing will not be provided. Initial: ______

Race/Ethnicity: __ White or Caucasian __ Black or African American __ Latino or Hispanic __ Asian __ Native Hawaiian or Other Pacific Islander __ American Indian or Alaska Native

__ Other ______

How did you hear about the MedEx Academy? ______

______

Have you participated in the Medical Explorers program? □ Yes □ No

If “Yes”, when and where did you participate in this program?

______

______

Have you participated in any Upstate AHEC Health career programs? □ Yes □ No

If “Yes”, when and where did you participate in this program?

______

______

MEDEX Academy

Application Continued

How many hours have you volunteered in a hospital or other medical establishment? □ None

□ 10 Hours or Less □ 20 Hours or Less □ 30 Hours or Less □ 40 Hours or Less

□ 50 Hours or Less □ More than 50 Hours

Do you have any limiting conditions that should be considered for the purpose of accommodating your needs: □ Yes □ No If yes, please explain:

______

In order to match participants with appropriate mentors, please list 3 health care areas in which you are interested.

(1)______

(2)______

(3)______

Transcripts must be submitted prior to the application deadline to Al Squire, Director, Workforce Development, Greenville Hospital System, 701 Grove Road, Greenville SC 29605. I understand my application is not complete unless my transcript is received by Al Squire by the application deadline of January 14, 2013. Initial here: ______

High School: ______City:______State: ______

Current Classification:  Jr.  Sr. Current cumulative GPA: ______

Expected Graduation (month and year): ______

List any relevant scholarships, awards & honors:______

______

List courses in which you are currently enrolled (note any lab courses): ______

______

List any AP, Honors and/or Magnet program in which you have participated: ______

______

MEDEX Academy

High School Student Application Continued

List any extracurricular activities (inside and outside of school) that you are involved in.

______

List any community service activities you have been involved in: ______

______

List any job experience you have (include dates, avg hrs/wk & responsibilities – attach separate sheet if necessary):

______

Please check the appropriate box for your level of knowledge in the following areas:

None / Basic / Intermediate / Advanced
MS Word
MS Excel
MS PowerPoint

Do you access to a laptop/computer at home? □ Yes □ No

Do you have access to the internet at home? □ Yes □ No

List any other technical skills that you have:______

______

MEDEX Academy

Application Continued

Note: Two letters of recommendation are required. (Reference forms attached) At least one letter should be from a faculty member at your school.

Reference #1: ______

(Name) (Relationship)

______

(School) (Address)

______

(City) (State) (Zip Code)

______

(Phone Number) (Email Address)

Reference #2: ______

(Name) (Relationship)

______

(School) (Address)

______

(City) (State) (Zip Code)

______

(Phone Number) (Email Address)

Note: An essay response is required for this application to be complete. The essay should be typedresponses to the following questions: (Limit to no more than 300 words)

  • Please describe your interests and personal thoughts about a future career in health care. Include your career goal(s).
  • What do you hope to gain from the MedEx Academy experience? List three learning objectives in your response.
  • What contributions can you make to the MedEx Academy? List three attributes.

I acknowledge that all of the information submitted in this application is correct and complete.

______

Signature Date

Participants are expected to dress in an appropriate manner while working at GHS. Personal appearance shall support patient care, create a healthy and safe environment, and not offend patients, visitors, employees, or other participants.

Identification Badges:

  • Worn with picture and name visible
  • Worn above the waist for easy identification
  • Clear of clutter (pins, stickers, etc.)

Clothing and Uniforms:

  • Should be clean, neat and follow hospital guidelines
  • Men: Shirt and ties for field experiences and business casual (shirt and khakis) for classroom experiences are the preferred attire.Ladies:Professional attire (dresses, pants, etc.) for field experiences. Business casual for classroom experiences are the preferred attire.
  • Hats, scarves, hair curlers or other headwear may not be worn, unless required for infection control purposes
  • The following list is NOT permitted while participating in MedEx Academy:
  • shorts, skorts, tank tops, T-shirts, jeans, halter tops, midriff shirts, leggings, warm up suits, crop, capri, and gaucho pants
  • tight fitting clothing
  • excessively baggy trousers and other clothing are not permitted
  • Clothing may not drag on the floor.
  • Clothes that inappropriately expose body parts or underclothing are not permitted.
  • clothes with messages
  • open-toed shoes, flip flops or sandals
  • visible tattoos

Jewelry:

  • Do not wear large earrings and long hanging jewelry
  • No pierced ornaments should be visible except in ear
  • Ears should not exceed two piercings per ear
  • Jewelry should be kept to a minimum
  • No more than two rings per hand
  • Only appropriate and professional jewelry may be worn
  • Facial jewelry may only be worn on the ears unless for bona fide religious reasons. No more than three earrings per ear will be considered appropriate.
  • Tongue and dental jewelry is not permitted.

Hair, Fingernails and Perfume:

  • Hair should be clean, neat, and trimmed. Mustache should be clean, neat, and trimmed.
  • Hair color and contact lenses must be consistent with colors occurring naturally in humans
    Nail coloring, lipstick, and other make-up must be consistent with the expected appearance of a healthcare professional.
  • Fingernails should not prevent a job from being done efficiently, safely, or with proper hygiene.
  • Excessively long fingernails (artificial or real) shall not be allowed.
    Artificial nails or nail polish is discouraged in direct patient care areas, and when worn, should not be chipped or peeling.
  • Perfume or other strong smelling scents should not be worn.

Students must follow any other department specific guidelines as applicable. Entering my name here serves as my electronic signature acknowledging that I have read and agree to adhere to the Dress Code/Grooming Guidelines for MedEx Academy. I understand that if I do not adhere to these guidelines, I may be excused from my activities with the MedEx Academy.

______

Signature Date

Rev. 10/11