R.E.A.C.H Program Application

Summer R.E.A.C.H. Program

June 24-26, 2019
Applicant Information
Full Name *

First Name Last Name
Birthdate *

- Month - Day Year

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

- Area Code Phone Number
E-mail *
Education
Elementary School *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

From (Start Date) *
To (End Date) *
Middle School *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

From (Start Date) *
To (End Date) *
Paragraph
Please write a short paragraph (8-10 sentences) about your interest in the Healthcare Field and why you are a good candidate for this program.
Emergency Contact Information
Parent/Guardian 1 Name *

First Name Last Name
Primary Phone Number *

- Area Code Phone Number
Work Phone *

- Area Code Phone Number

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Parent/Guardian 2 Name

First Name Last Name
Primary Phone Number

- Area Code Phone Number
Work Phone

- Area Code Phone Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Alternative Emergency Contacts
Primary Emergency Contact *

First Name Last Name
Primary Phone Number *

- Area Code Phone Number
Work Phone *

- Area Code Phone Number

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Secondary Emergency Contact

First Name Last Name
Primary Phone Number

- Area Code Phone Number
Work Phone

- Area Code Phone Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Medical information
Hospital/Clinic Preference *
Physician's Name *
Phone Number *

- Area Code Phone Number
Insurance Company *
Policy Number
Please List any Allergies or Special Health Considerations below
Disclaimer
Media: I grant South Texas Medical Academy for Medical Professions and South Texas ISD permission to make photographs, videotapes, broadcasts, and/or sound recordings, separately or in combination, of me and permission to use the said photographs, videotapes, broadcasts, and/or sound recordings for educational and promotional purposes on any delivery system. Furthermore, I understand that any such photographs, videotapes, sound recordings, or academic work become property of South Texas Academy for Medical Professions and South Texas ISD.

Medical: I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.

I release South Texas Academy for Medical Professions and individuals from liability in case of accident during activities related to Summer R.E.A.C.H. Program, as long as normal safety procedures have been taken.

In submitting this form I agree to these details being used for the purpose of screening applicants for the Summer R.E.A.C.H. Program. The information will only be accessed by necessary staff. I understand my data will be held securely and will not be distributed to third parties. I have a right to change or access my information. I understand that when this information is no longer required for this purpose, official school procedure will be followed to dispose my data.

I certify that all information is true, reliable, and complete to the best of my knowledge.

Typing your name at the end of the application and clicking the submit button will constitute your electronic signature
By clickin on "I Accept" you are agreeing that you have read and understood the above statement and consent to submitting your application electronically *

I Accept I Decline
Child's Name *
Parent/Legal Guardian Name *
*

- Month - Day Year
Should be Empty:

Summer R.E.A.C.H. Program

Applicant Information

Education

Paragraph

Emergency Contact Information

Alternative Emergency Contacts

Medical information

Disclaimer