Careers in Health - Advanced Summer Experience
Summer of 2026
I. DEMOGRAPHICS
High School:
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School County:
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Please Select
Clark
Mason
School Phone:
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Graduation Year:
*
First Name:
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MI:
Last Name:
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Address:
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City:
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State:
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Zip Code:
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Home Phone:
Cell Phone:
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Alternate Phone:
Email Address:
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Date of Birth:
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-
Month
-
Day
Year
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Are you a US Citizen?
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Yes
No
Gender:
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Male
Female
Prefer not to say
Other
Race / Ethnicity:
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African-American
Caucasian
Hispanic
Asian or Pacific Islander
Native American or Alaskan
Other
Have you ever been required to leave school for disciplinary reasons?
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Yes
No
If yes, please explain:
Please Upload your headshot for your badge if you are selected to participate in CHASE. The photo will need to be front-facing.
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Why do you want to participate in Careers in Health - Advanced Summer Experience?
II. HOUSEHOLD / EMERGENCY CONTACT INFORMATION
Emergency Contact:
Name:
*
Relationship:
*
Phone Number:
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-
Area Code
Phone Number
Is this person's address different than your address?
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Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
III. ESSAY
Essays will allow the application review committee to get a better understanding of the student's personality and expectations. Essays will be evaluated on clarity of thought, writing quality, and grammar.
TYPE
and
DOUBLE-SPACE
your writing entry.
Essay (200 words) - Why are you choosing health careers as your field of interest after high school? What is your future career goal and how would Careers in Health - Advanced Summer Experience help you in achieving that goal?
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File must be pdf, doc, docx, jpg, or png format
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IV. MENTOR FOCUS AREA
Which health care career interests you the most?
V. STUDENT CONSENT AND AGREEMENT
By signing my digital signature below, I hereby certify that the information provided on this application and attachments I have provided is true and accurate to the best of my knowledge and that the writing entry is my original work. I commit myself to abide by the rules and expectations of this program.
Signature
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/
Month
/
Day
Year
Date
VI. PARENT/GUARDIAN CONSENT FORM
Please download the CHASE consent form below.
In order for your application to be accepted, a signed copy of the CHASE Guardian Consent Form must be submitted. Forms may also be uploaded here or submitted by email to kellie.jones@uky.edu, or by mail or in-person to: Northeast KY AHEC, Attention: Kellie Jones. 316 W. 2nd St. STE. 203 Morehead, KY 40351.
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