LAUNCH Academy

Student's Name* This field is required.

First Name

Last Name

Student's Email Address* This field is required.

example@example.com

Email Verified

The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification

••••

Student's Home Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Student's Phone Number* This field is required.

Area Code

Phone Number

Student's Age* This field is required.

Student's Birthday (Format: Month - Day - Year)* This field is required.

Student's Birthday

Date

Student's Gender* This field is required.

Male

Female

Prefer to self-describe

Prefer not to say

Student's Race* This field is required.

Student's Current Grade* This field is required.

9th

10th

11th

12th

Student's School Name* This field is required.

Are you currently enrolled in any healthcare courses at your school?* This field is required.

Yes

List the healthcare course(s) that you are currently enrolled in.

Have you completed any healthcare courses?* This field is required.

Yes

List the healthcare courses that you have completed?

Student's Shirt Size* This field is required.

Adult Small

Adult Medium

Adult Large

Adult X-Large

Adult 2XL

Adult 3XL

Any allergies or health concerns? If "yes", please specify:

Please select all LAUNCH program(s) that Student has attended previously.* This field is required.

Student has not attended any LAUNCH programs

Summer Camp 2017

Summer Camp 2018

Summer Camp 2019

Virtual Session 2020

Academy 2021

Summer Camp 2021

Academy 2022

Summer Camp 2022

Academy 2023

Summer Camp 2023

Academy 2024

Summer Camp 2024

Student's Career Goal* This field is required.

Parent's (Legal Guardian) Name* This field is required.

Parent's Contact Email Address

Parent's (Legal Guardian) Email Address* This field is required.

example@example.com

Parent's (Legal Guardian) Contact Phone Number* This field is required.

Area Code

Phone Number

Student Short Essay Question #1* This field is required. Why do you want to pursue a career in healthcare?

Student Short Essay Question #2* This field is required. What do you hope to accomplish by attending LAUNCH Academy?

Please attach a copy of a recent report card, progress report, or transcript.* This field is required. Please attach a copy of a recent report card, progress report, or transcript.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Please provide the following information for your Recommender.* This field is required.A link to the recommendation form will be sent to your recommender upon submittal of your application. Make sure to communicate with the person you have listed as a contact prior to submitting your application so he/she will know that the link is coming. The recommendation form must be completed by November 1st at 9 am.

Name

Title/Relationship

Phone

After review of all Student Application packages, a selected amount of Students will be chosen to interview virtually. If chosen, you will receive an email from Hireflix interviewing company to complete the interview. (Don't forget to check your SPAM folder). Please click the box below if you understand the interview process.* This field is required.

I understand the interview process. I also understand that it is my responsibility to complete my interview virtually.

If chosen to join the LAUNCH Academy cohort, can you commit to attend ALL of the following dates: January 25th, February 22nd, March 22nd, and April 26th?* This field is required.

YESNO

How did you hear about LAUNCH Academy?* This field is required.

For funding and data collection purposes: What is the total number of people in your family unit (including Student & Parent that is completing this form)?

10 or more

For funding and data collection purposes: What annual income range best describes your total gross household yearly income?

Less than $27,862

$27,862 - $37,814

$37,815 - $47,767

$47,768 - $57,720

$57,721 - $67,673

$67,674 - $77,626

$77,627 - $87,579

$87,580 - $97,532

More than $97,532

For funding and data collection purposes: Who does the Student live with?

Both Parents

Mother only

Father only

Grandparent

Foster Parent

Legal Guardian

For funding and data collection purposes: What County does the Student reside in?* This field is required.

For funding and data collection purposes: Did either of your parents complete a 4-year college degree (Bachelor's degree)?* This field is required.

By signing below, I certify that all information recorded above is correct and accurate. * This field is required.

Clear

LAUNCH Academy is provided by LAUNCH Augusta through partnership with Doctors Hospital.

LAUNCH Academy