Health Academy Summer Experience
Southern Regional Area Health Education Center
Health Careers Workforce Diversity Program
1601 Owen Drive  Fayetteville, NC 28304  910-678-7201 / 910-678-7224
Program Summary
This is one-week residential summer programs for high school student’s grade 9-12 who have an interest in health
careers. During the program students conduct scientific research; participate in Health and Leadership workshops; visit
medical schools; and shadow health professionals at a local hospital. The program dates are scheduled on:
June 25-30, 2017, at University of North Carolina at Pembroke in Pembroke, North Carolina.
Application Instructions
AN APPLICATION WILL BE REVIEWED ONLY AFTER RECEIPT OF ALL REQUESTED MATERIALS. Applications must be
postmarked by Friday, May 5, 2017. Incomplete applications and any material not postmarked by this deadline will
not be considered.
PLEASE NEATLY PRINT OR TYPE YOUR APPLICATION. Be sure to answer each item in its entirety. If you find it
necessary to elaborate on any subject, please use additional sheets. All materials within your application packet become
the property of the Health Academy Summer Experience. These materials are kept confidential by the Southern
Regional Area Health Education Center, Health Careers, and Workforce Diversity Program.
Eligibility Requirements
All participants must have a minimum GPA of 3.0 to be considered for the program, and provide official documentation
from an accredited school. Applicants must be U.S. citizens or have appropriate visa.

Transcript: Contact your current school to request an official transcript be mailed to: Southern Regional AHEC,
Attn: Tonya Burney, 1601 Owen Drive Fayetteville, NC 28304.

Faculty Appraisal Forms: An appraisal form must be completed by two academic teachers and returned with
the complete application packet.

Essay: Compose an essay in 100-200 words explaining your career interest and reasons for wanting to attend
the Health Academy Summer Experience. Typed essays are preferred.

Photograph: Attach a current photograph with the application form in the space provided.
Candidate Selection
Candidates will be notified by mail within two weeks after the application deadline. Once the acceptance letter is
received, a $75 nonrefundable processing fee must be paid to reserve your space by May 26, 2017. Proof of health
insurance, code of conduct, consent to photograph, immunization records and the remanding balance of $150 are due
by June 9, 2016. Total Fee: $225.00

Proof of Health Insurance: After receiving your acceptance letter, you will need to provide a copy of your health
insurance card. Health insurance must be current to attend the summer program.

Immunization: After receiving your acceptance letter you will be required to provide a copy of your
immunization record. You must have received a tetanus shot within the past 10 years.

Status Requirements: All students must be prepared to attend the program in its entirety to be eligible. No
absences will be allowed. It is the parents/guardians’ responsibility to keep the Health Academy Summer
Experience Program Director informed of any changes in a student’s personal status (e.g., address and
telephone numbers, health insurance coverage, health status, etc.) For application questions or status updates,
please call 910-678-7201 or 910-678-7316.
Health Careers Application Set 2015
Application Form
Health Academy Summer Experience
Southern Regional Area Health Education Center
Health Careers and Workforce Diversity Program
1601 Owen Drive  Fayetteville, NC 28304
Tel: 910-678-7201 Fax: 910-678-0106
Application Date:
Age at Application Time:
Name: (First, Middle, Last)
 Male  Female
Preferred Nickname:
Last 4 of SSN: XXX-XX
Date of Birth (00/00/0000):
 Asian American
 American Indian
 Black/African American
 Latino/Hispanic
 White/Caucasian
 Other, specify
Current Mailing Address:
City/State/Zip:
Home Phone: (
)
Cell Phone: (
)
Cell Phone: (
)
Email Address:
Name of Parent(s) or Guardian(s)
Address
 Same / or
Home Phone: (
)
Email Address:
Classification: Rising
 9th  10th  11th  12th
Career Interests:
Current School:
Address:
Affix
Current
Photo
Here
City/State/Zip:
Telephone: (
)
Graduating Class Year:
T-shirt size:
Small
Medium Large XL XXL XXXL
Health Careers Application Set 2015
Student’s Name: (First, Middle, Last):
Describe all known medical conditions, including food allergies and/or drug allergies.
List any and all over-the counter medicines, vitamin supplements, and any prescriptions taken regularly.
If a child becomes ill while in attendance, the individuals named below will be contacted in the order provided.
Primary
Emergency Contact:
Home Phone: (
Relationship
)
Cell/Work Phone: (
)
Alternate
Emergency Contact:
Home Phone: (
Relationship
)
Cell/Work Phone: (
)
Physician’s Name:
Address:
Phone:
(
)
(
)
Dentist’ Name:
Address:
Phone:
AUTHORIZATION
Southern Regional AHEC shall have the authorization to obtain medical treatment and procedures for the student, as
may be appropriate in emergency circumstances, including treatment by physicians, hospital and clinic personnel, and
other appropriate healthcare providers while the student is attending the academy. In addition, SR-AHEC is granted
permission to obtain medical treatment from appropriate healthcare providers if symptoms of illness occur (e.g., fever,
coughing, irregular breathing, unusual rashes, swallowing problems, etc.)
Special Care Notes:
X SIGNATURE of
Parent/Guardian:
PRINT NAME:
Health Careers Application Set 2015
Date:
Essay Submission
Health Academy Summer Experience
Southern Regional Area Health Education Center
Health Careers and Workforce Diversity Program
Type Name:
Please use the space below to compose an essay in 200 - 300 words explaining your goals,
motivations, and reasons for wanting to attend the Health Academy Summer Experience.
Health Careers Application Set 2015
Faculty Appraisal Form
Health Academy Summer Experience
Southern Regional Area Health Education Center
Health Careers and Workforce Diversity Program
1601 Owen Drive  Fayetteville, NC 28304
Tel: 910-678-7201 Fax: 910-678-0106
Please print or type your responses below and return this form to the address above.
Student’s Name:
I,
have known the applicant for a period of
in the following capacity:
The applicant ranks academically with other students I have taught in recent years as follows:
 Top 5%
 Top 10%
 Top 25%
 Average
 Below Average
On a scale from 1-5, please rank the applicant on the following traits, relative to other students you have taught.
Poor=1, Fair=2, Average=3, Good=4, Excellent = 5
CHARACTERISTIC
Rank on a
scale 1-5
Have not
observed
N/A
Additional comments
Intellectual Ability
Communications Skills
Emotional Stability
Study Habits/Skills
Attendance/Punctuality
Comprehension
Attention to Detail
Judgment
Motivation/Perseverance
Dependability
Initiative
Cooperative Attitude
Ingenuity
Leadership
Please list major strengths of this student as a prospective participant:
Position Title:
Department:
School/Institution:
City/State/Zip:
Best Telephone Number to Reach You: (
Signature:
Health Careers Application Set 2015
)
Date:
Faculty Appraisal Form
Health Academy Summer Experience
Southern Regional Area Health Education Center
Health Careers and Workforce Diversity Program
1601 Owen Drive  Fayetteville, NC 28304
Tel: 910-678-7201 Fax: 910-678-0106
Please print or type your responses below and return this form to the address above.
Student’s Name:
I,
have known the applicant for a period of
in the following capacity:
The applicant ranks academically with other students I have taught in recent years as follows:
 Top 5%
 Top 10%
 Top 25%
 Average
 Below Average
On a scale from 1-5, please rank the applicant on the following traits, relative to other students you have taught.
Poor=1, Fair=2, Average=3, Good=4, Excellent = 5
CHARACTERISTIC
Rank on a
scale 1-5
Have not
observed
N/A
Additional comments
Intellectual Ability
Communications Skills
Emotional Stability
Study Habits/Skills
Attendance/Punctuality
Comprehension
Attention to Detail
Judgment
Motivation/Perseverance
Dependability
Initiative
Cooperative Attitude
Ingenuity
Leadership
Please list major strengths of this student as a prospective participant:
Position Title:
Department:
School/Institution:
City/State/Zip:
Best Telephone Number to Reach You: (
Signature:
Health Careers Application Set 2015
)
Date: