H.E.L.P Application

Application - High School

Admission Criteria: 9th-12th grade, reside in Phillips County and have an interest in learning about healthcare careers.
Personal Information
Student Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Ethnic Background*
Home Phone*
Cell Phone
Primary email*
Check your email frequently for scholarship opportunities.
Academic Information
School Name*
Current Grade*
What are your plans after high school?*
College, Work, Not Decided
Are you considering a career in healthcare?*

YesNo
Majors you are Considering

List majors in order of preference, please note that many majors can be applied to healthcare careers. For example, if you have an interest in Business, place that in the field.
Major 1
Major 2
Major 3
Parent/Guardian Info
Parent or Guardian Name*
First and Last
Parent E-mail Address
First, Last
Did your parent(s) graduate from college?*

YesNo
Where is your father/guardian employed?*
Where is your mother/guardian employed?*
Household Size*
Activities & Experiences
Did you participate in school activities/clubs?*

YesNo
Did you participate in sports?*

YesNo
Have you participated in community service or volunteering activities?*

YesNo
Do you have work experience?*

YesNo
School Activities/Clubs

List school activities/clubs you have participated in.
School Activities/Clubs
Name of Activity, Office held, Grade level
Sport Participation

List sports you have participated while attending.
Sport Participation
Name of Sport, Sport level, Grade level
Community Services and/or Volunteering Activities

List community services and/or volunteering you have participated in.
Community Service/Volunteering
Name of organization, # of hours volunteered, Duties
Emergency Contact

Please enter the contact information regarding emergency contact.
Emergency Contact Name*
First and Last
Phone Number*
(area code) Number
Relationship*
Mom, Dad, Aunt, Uncle, Grandparent
Summary

Please use the box below to explain why you want to be apart of this program.
Should be Empty:

Application - High School

Personal Information

Academic Information

Majors you are Considering

Parent/Guardian Info

Activities & Experiences

School Activities/Clubs

Sport Participation

Community Services and/or Volunteering Activities

Emergency Contact

Summary