Future Doctors 2023 Application
Student Name
*
First Name
Last Name
Student Email
*
example@example.com
Student Phone Number
*
(000) 000--0000
Gender
*
Please Select
Male
Female
Grade
*
Please Select
9th
10th
11th
12th
High School Name
*
Select your preferred dates for the program. *Select all if you have an open availability
*
Cohort 1: June 12 - June 16
Cohort 2: July 10 - July 14
Cohort 3: July 24 - July 28
Scrub Size
*
Please Select
XS
S
M
L
XL
XXL
Dietary Restrictions
*
Guardian Name
*
First Name
Last Name
Guardian Email
*
example@example.com
Guardian Phone Number
*
(000) 000--0000
Relationship to Student
*
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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Financial Aid
Do you need financial aid? Please select NO if you do not fall under the Federal Poverty Guidelines. https://texaslawhelp.org/article/federal-poverty-guidelines
*
Please Select
Yes
No
ACKNOLEDGMENT
*
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Upload your resume
*
List your extracurricular activities, leadership positions, and any honors or awards you have received.
*
Application Essay
*
In 200-300 words, please tell us how the Future Doctors program aligns with your goals and how it will help you reach them.
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Payment Page
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Future Doctors 2023
$
1,800.00
Enter coupon
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Total
$
0.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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Informed Consent & Confirmation
I hereby state that my child is in good mental and physical health condition to participate in all of the activities and classes at GEM. I hereby give my approval for my child’s participation in any and all activities prepared by GEM Multicultural Center during the selected program. I assume all risks and hazards incidental to the conduct of the activities, and release, absolve, and hold harmless GEM Multicultural Center. and all its respective officers, agents, and representatives from any and all liability for injuries to the said child arising out of traveling to, participating in, or returning from the selected program. I hereby release GEM Multicultural Center from any and all liability, claims, suits, demands, judgments, costs, interest, and expenses (including attorney fees and costs) arising from, or related to, such activities and/or any related activities, including any accident or injury to the student and the costs of medical services. I also agree not to hold these parties responsible in the event that myself/Son/daughter engages in inappropriate conduct (including, but not limited to disruptive or volatile behavior in or out of the center, etc.) or become involved in any activity or with any persons not associated with this program. I further attest that the information contained in this application is correct to the best of my knowledge. I hereby allow my self/child to be photographed and videotaped at GEM Center for the purposes of the Center’s promotional material and publications.
Fees are refundable 7 days prior to the start of the camp date. A 3% service fee will apply to all refunds
Signature
Clear
Date of Consent
*
-
Month
-
Day
Year
Date
How did you hear about us?
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