Greensboro Area Health Education Center (AHEC)
& North Carolina A&T State University
Department of Chemistry
1601 East Market Street
Greensboro, North Carolina 27411
APPLICATION PACKET
Application Deadline has been extended
APPLICATION INSTRUCTIONS
NOTE: APPLICATION WILL BE REVIEWED ONLY AFTER RECEIPT OF ALL REQUESTED MATERIALS.
The Preparation of Underclassmen for Science and Healthcare (PUSH) Program, coordinated by the
North Carolina A&T State University, Department of Chemistry, is sponsored by the Greensboro Area
Health Education Center (AHEC). The program is scheduled for two weeks beginning June 16, 2014June 27, 2014. A Student/Parent Orientation will be held at North Carolina A & T State University in
Greensboro, North Carolina on Monday, June 16, 2014 at 8 a.m.
All materials within your application packet become the property of PUSH. These materials are kept
confidential by North Carolina A&T State University, Department of Chemistry and Greensboro AHEC.
PLEASE NEATLY PRINT OR TYPE YOUR APPLICATION
1. ELIGIBILITY: All applicants must be U.S. citizens or have appropriate visa. To be eligible to attend
PUSH, an applicant must be a rising 9th grade student. Applicants must have intent on pursuing a career
in science or medicine. Applicants must have earned a grade of B or better in Science and Math courses.
A Copy of final report is required.
2. GUIDELINES: When completing your application, please acknowledge or address each item. If you
find it necessary to elaborate on any items, use additional sheets. Write your name and last 4 digits of
your social security # on additional pages.
3. ESSAY: Prepare a personal statement of approximately 250 to 500 words explaining your background,
career goals, motivations and reasons for wanting to attend the PUSH Program. Indicate the benefits
you expect to receive and explain any special aspects of your preparation and/or record that might
contribute to the program. The statement should be typed and submitted with the Application Packet.
4. TEACHER EVALUATION FORM: Teacher evaluation form must be completed by a current science
teacher or guidance counselor and included in the Application Packet enclosed in a sealed and signed
envelope.
5. CORRESPONDENCE: ALL APPLICATIONS and CORRESPONDENCE should be sent to AHEC, 1200 North
Elm Street Attn: Health Careers / Patricia Parrish Greensboro, NC 27401 by May 5,2014.
6. CANDIDATE SELECTION: Applicants will be notified by email. *NOTE: All students must be prepared
to attend the program in its entirety to be eligible, no absences will be allowed - this includes vacations
and holidays.
REGISTRATION FORM
PLEASE PRINT. USE BLACK OR BLUE INK.
Applicant Name
Gender
Race/Ethnic Origin
Phone Number (
Birth date
)
Mailing Address
(Street No./PO Box
(City)
Name of School
(State)
Zip)
Grade (Fall 2014)
Mother/Guardian
Phone No. (Home)
Cell
Work
Address:
(City)
(State)
(Zip)
Mother’s Email Address:
Father/Guardian
Phone No. (Home)
Cell
Work
Address:
(City)
(State)
(Zip)
Father’s Email Address:
In the event parents can’t be reached who should be contacted:
Name
(Home)
Address:
List any disabilities:
List any allergies:
List any medical condition(s) we should be aware of:
List Medication(s) being taken
(Cell)
List all school/Community achievements:
Are you participating or interested in other AHEC health career programs?
Yes
No
Parent Consent
I,
am aware
(Applicant’s name)
Is registering for the PUSH Program and hereby give my permission for participation.
Parent Signature
Date
Application with payment must be received prior to start of camp.
Check/Money Order payable to Greensboro AHEC
Return application with a $100 Registration fee to:
Greensboro AHEC
1200 North Elm Street
Greensboro, NC 27401
ATTN: HEALTH CAREERS/ Patricia Parrish
LIMITED SPACE…. REGISTER EARLY.
PUSH Program
Program Registration Fee $100.00
(all materials, food, fieldtrips included in the registration fee).
CAMP POLICIES:
As a condition of enrollment, I understand that from time to time photographs may be taken of my child
engaged in various camp activities. My signature below indicates my knowledge that such
photographs/images may exist and expressly serves as a waiver allowing AHEC and NCAT to use these
photographs/images in promotional materials without monetary compensation for the use of such
photographs/images.
I also understand that the camp fee is non-refundable after June 1, 2014.
In an effort to ensure the safety and enhance the positive camp experience of each camper and to
comply with state and local laws governing educational institutions and in accordance with University
rules and regulations, the Division of Continual Learning has established to the following policies:
A camper may be expelled from camp without refund for violation of the
following rules:
1. Leaving the campus without explicit permission of the Director or his/her delegate.
2. Disruptive behavior that endangers or detracts from others’ camp experience.
3. Use or possession of tobacco products.
A camper may be expelled from camp without refund and may be subject to
prosecution for violation of the following rules:
4. Use or possession of illegal drugs or alcohol.
5. Possession of firearms or any other weapons as defined by NC General Statutes.
I have read, understand, and agree to the terms above.
Parent/Guardian Signature
Date
/
/20
Camper Signature
Date
/
/20
Medical Release Form 2014
Camper: Name
Goes by
Male
Female
Phone (
)
Phone (
)
Date of Birth:
Family Physician
Medical Insurance Carrier
Carrier Address
Policy/Group #
1st Parent/Guardian
Home # (
)
Best time to be reached
Work # (
)
Best time to be reached
Cell # (
)
Best time to be reached
Home Address
(City)
(State)
(Zip)
2nd Parent/Guardian
Home # (
)
Best time to be reached
Work # (
)
Best time to be reached
Cell # (
)
Best time to be reached
Home Address
(City)
Chronic or recurring illness or medical conditions
(State)
(Zip)
The applicant is under the care of a physician for the following condition(s)
Explanation of any reported loss of consciousness, convulsion, or concussion
Any medically prescribed meal plan or dietary restrictions:
NO
YES
IF YES, explain
Any allergies (food, drugs, plants, insects, etc.):
NO
YES
IF YES, explain
Activities to be encouraged or limited:
NO
YES
IF YES, explain
Health history: Circle all that apply
Frequent ear infections
Heart defect/disease
Bleeding/clotting disorders
Diabetes
Hypertension
Chicken Pox
Mononucleosis
Hay fever
Ivy poisoning, etc.
Asthma
Penicillin allergy
Asthma
Seizure (last seizure date)
Allergies requiring epi-pen
Other (specify)
Prescription drugs
I am the parent/guardian of the above named child, and give consent for my child to attend the PUSH Day Camp. I
understand that my child’s participation will include some physical activity. I acknowledge that injuries may occur
as a result in the participation in this camp, and I accept that consequence. I have advised our family physician
that my child wishes to participate in the PUSH Day Camp, and our physician has approved of this participation. I
authorize camp personnel to act according to their best judgment to provide medical care. I give permission for a
physician or hospital emergency room to administer the necessary care. I give permission to camp staff health
professionals to view and maintain my camper’s medical records during camp and to share them with medical
personnel in case of an emergency. I understand and agree that I am responsible for any charges for medical
treatment.
Parent/Guardian Signature:
Date:
PUSH TEACHER EVALUATION FORM
I. STUDENT
Fill in your name and address. Give your evaluation form and an addressed envelope to one of your
teachers or guidance counselor. Request them to give the completed rate form back to you in the
sealed envelope for inclusion in your application packet.
Student Name:
Address:
II. RECOMMENDER
This student is applying to the PUSH program at NC A&T SU. The program considers students who are
seriously planning on pursuing higher education in health careers, math and science.
Your candid evaluation would be very helpful in selecting qualified participants for this program. We are
interested in whatever you think is important about the applicant’s academic and personal
qualifications. Please insert the completed evaluation form in the provided envelope, and sign the back
flap of the envelope. Return the envelope to the student for inclusion in their application packet. We
are grateful for your assistance.
1. I have known the applicant for a period of
in the following capacity:
2. The applicant ranks academically with other students taught in recent years as follows:
Top 5%
Top 10%
Top 25%
Average
3. Major strengths of this student as a prospective participant in the PUSH program are:
Below Average
4. Major weaknesses of this student as a prospective participant in the PUSH program are:
5. The applicant in relation to perceived ability to successfully pursue higher education in health
careers math and science is rated as follows:
Excellent
Average
Very Good
Below Average
Good
Poor
No observation
6. Please rank the applicant on the following traits, in comparison with other students you have
taught.
TRAIT
1. Intellectual ability
2. Academic achievement
3. Ability to communicate
4. Emotional stability
5. Disciplined study habits
6. Attention to details
7. Sense of responsibility
8. Cooperative attitude
9. Self confidence
10. Potential for growth
One of the few
encountered in
my career
Excellent
Very
Good
Good Average
Below
Average
No support to
observe
7. The applicant is recommended:
Enthusiastically
Recommended with reservation
With Confidence
Not recommended
Recommended
No basis for recommendation
Any other comments:
8. Name
Title
Department
Telephone (
Signature
University
)
Fax
Date