2022-2023 Health Careers Academy

Health Careers Academy

Application
Thank you for your interest in the 2022-2023 Health Careers Academy. The Health Careers Academy is an exploratory program designed for 9th - 12th graders who are interested in or curious about pursuing the field of healthcare.

This year in light of the ongoing pandemic, we will only be offering virtual programming once a month starting in September. Our goal is to resume in-person programming as soon as it is safe to do so!

If you are interested in participating in our program, please click next and continue to the application.

Please note that we encourage that parents allow their students to complete this form and list their own contact information in the student portion so that we may communicate directly with the student intended to receive our services.

PARENT CONTACT & FAMILY INFORMATION
Parent/Guardian Name *

First NameLast Name
Relationship*
Parent/Guardian Phone Number*
Parent/Guardian Email Address*
example@example.com
Would you like to add contact information for another Parent/Guardian? *
Parent/Guardian Name *

First NameLast Name
Relationship*
Parent/Guardian Phone Number*
Parent/Guardian Email Address*
example@example.com
Number of Immediate Family Members Currently living in the household (including self)

Academic Information
Current Academic Institution*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Anticipated Graduation *

MonthDayYear
Date
Current Grade*
What grade will you be in for the upcoming school year?
Guidance Counselor Name*
Guidance Counselor Email
example@example.com
READ BEFORE PRESSING SUBMIT.

By pressing submit on this form, I am confirming that the information provided is correct to my knowledge and that I am interested in participating in the Health Careers Program offered by Upstate Area Health Education Center (AHEC).

I understand that participation in this program is voluntary on my part, however will require additional permission to participate from my parent or guardian if I am under 18.

I also understand that the enrollment is open as long as the program has not reached capacity and it is possible that my application may be received below that marker. At that point, I will be moved to a waiting list until space opens. I will still receive access to other AHEC resources and programs but may not be able to physically participate in the Health Careers Academy.
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