Student Applicant Information
Please complete all questions below:
Did you participate in the "Camp Fast Forward" program last summer?
*
Yes
No
Home Parish:
*
Please Select
Allen
Avoyelles
Catahoula
Concordia
Grant
LaSalle
Natchitoches
Rapides
Vernon
Winn
Which parish does the student applicant currently reside in?
Student Applicant Name
*
First Name
Last Name
Student Applicant Date of Birth
*
-
Month
-
Day
Year
Date
Student Applicant Gender:
*
Please Select
Male
Female
Preferred Phone Number
*
Please enter a valid phone number. Central LA AHEC may use this number to send out program reminders. Please make certain that you have access to this phone number and you are able to receive text messages.
Preferred Email
*
DO NOT USE a school or state email as this sometimes is rejected by the email server. All communication concerning this program will come via email. Please make certain that you have access to this email account.
Name of School currently attending:
*
Current school grade level?
*
Please Select
7th Grade
8th Grade
Name of School entering in Fall of Academic Year 2024-25:
*
What grade will student applicant be entering in the 2024-2025 academic year?
*
Please Select
8th Grade
9th Grade
Student Applicant Ethnicity / Race:
*
African American/Black
American Indian
Asian
Caucasian/White
Hispanic
Pacific Islander
Other
This program requires that the student have daily transportation to and from the camp site. Although this is not guaranteed, which site is preferred:
*
CLTCC- Avoyelles Parish (Cottonport) **June 10-13
CLTCC- Concordia Parish (Ferriday) **June 10-13
CLTCC- LaSalle Parish (Jena) **June 10-13
CLTCC- Rapides Parish (Alexandria) **June 10-13
CLTCC- Winn Parish (Winnfield) **June 10-13
LSU-Alexandria **June 24-28
Northwestern State University (Natchitoches) **June 24-27
SOWELA- Vernon Parish (Leesville) **June 3-6
Other
Did my child participate in the MedStart program at his/her school during this school year? This year, this program was only offered at the following schools: Avoyelles Public Charter, Marksville High, LaSAS, Jena Jr. High, LaSalle Jr. High, Alexandria Middle Magnet School, Brame Middle School, Glenmora High School, Northwood High School, and Poland Jr. High.
*
YES
NO
Funding for this program is provided by The Rapides Foundation. I understand that if my child is selected to participate in this summer camp, my child must attend ALL camp days. Failure to attend all camp days could disqualify my child from future Central Louisiana AHEC program opportunities.
*
YES
NO
Transportation for this program is not available. Do you have reliable transportation to and from the camp site each day?
*
Yes
No
Student Applicant T-Shirt Size:
*
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult 2X-Large
Adult 3X-Large
Adult 4X-Large
Student Applicant Career of Interest:
*
Please list up to 3 careers that student is potentially interested in.
Student Applicant Phone Number
*
Please enter a valid phone number.
Parent Phone Number
*
Please enter a valid phone number.
Student Applicant Mailing Address
*
Address
Address Line 2
City
State / Province
Postal / Zip Code
Student Applicant Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Guardian Contact Information
Mother/Legal Guardian Name and Relationship
*
Full Name
Relationship to Student Applicant
Mother/Legal Guardian Phone Number
*
Please enter a valid phone number.
Mother/Legal Guardian Email
*
example@example.com
Father/Legal Guardian Name and Relationship
Full Name
Relationship to Student Applicant
Father/Legal Guardian Phone Number
Please enter a valid phone number.
Father/Legal Guardian Email
example@example.com
Emergency Contact Information
Emergency Contact Name and Relationship
*
Full Name
Relationship to Student
Emergency Contact Phone Number
*
Please enter a valid phone number.
Student Applicant Health Information
Please list all medical conditions, if any, for the Student Applicant:
*
If none, please put N/A
Please list all allergies, if any, for the Student Applicant:
*
If none, please put N/A
Physician Name
*
First Name
Last Name
Physician Phone Number
*
Please enter a valid phone number.
Please upload a copy of the FRONT of the student applicant health insurance card:
*
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Please upload a copy of the BACK of the student applicant health insurance card:
*
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Please upload your current report card.
*
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Please upload your completed student assessment provided to you by a school faculty member.
*
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Signature
Date
-
Month
-
Day
Year
Date
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