A.T. Still University & Truman State University's
Summer Healthcare Career Experience (SHCE)
Welcome to the SHCE application process!
Please Note:
- Completed applications must be submitted by February 28, 2017 deadline.
- Application materials will be reviewed by both A.T. Still University and Truman State University Admissions Departments, as well as Missouri Area
Health Education Center personnel.
- A copy of your high school transcript must be included with your application.
- Additional applications may be obtained by contacting the A.T. Still University Admissions Office or at www.atsu.edu/learn.
Last Name
First Name
(Preferred Name)
Middle Initial
PO Box/Rural Route
Street Address
State
City
County
Email Address
Female
Male
Zip Code
Phone Number (Including Area Code)
Racial Category(Optional)
Check as many as apply.
Are you Hispanic or Latino?
(Optional)
Gender:
Date of Birth
Yes
American Indian or Alaskan Native
No
Asian
Black or African American
Shirt Size:
Small
X-Large
Medium
2XL
Native Hawaiian or Other Pacific Islander
White
Other
Large
Grade:
Name of High School Currently Attending
Current Year in School
School Address
City
School Counselor Name
Phone Number (Including Area Code)
State
County
School Counselor Phone Number
(Including Area Code)
Application Deadline: February 28, 2017
Zip Code
School Counselor Email Address
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A.T. Still University & Truman State University's
Summer Healthcare Career Experience (SHCE)
Essay Questions for the SHCE Academy
Please respond to the questions below in ESSAY FORM.(Limit: 300 words per question.)
1. What health careers are you currently interested in and why?
2. What have you done to investigate the health career(s) that interest you?
Application Deadline: February 28, 2017
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A.T. Still University & Truman State University's
Summer Healthcare Career Experience (SHCE)
Essay Questions for the SHCE Academy
Please respond to the questions below in ESSAY FORM. (Limit: 300 words per question.)
3. What special skills or qualities will you bring to SHCE?
4. What do you hope to accomplished from attending SHCE?
Application Deadline: February 28, 2017
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A.T. Still University & Truman State University's
Summer Healthcare Career Experience (SHCE)
I certify that the application was completed by me (the student) and that all information is accurate. I understand that falsification
of any information on this application may result in my being disqualified from the application process and/or SHCE. If I am
selected for SHCE and choose to participate, I agree to abide by all program rules and guidelines. I understand that I must
participate in the entire program on the dates scheduled for these events. I also understand that all application materials will
be reviewed by the A.T. Still University and Truman State University Admissions Departments. Applicant information will
also be provided to the Missouri Area Health Education Center personnel for follow-up to other local health-related
programs.
Student Signature
Date
Nondiscrimination Policy
ATSU does not discriminate on the basis of race, color, religion, ethnicity, national origin, sex (including pregnancy), gender, sexual orientation,
gender identity, age, disability, or veteran status in admission or access to, or treatment or employment in its programs and activities. Dating
violence, domestic violence, sexual assault (e.g. non-consensual sexual contact/intercourse), stalking, harassment, and retaliation are forms of
discrimination prohibited by ATSU. Any person who witnesses or has knowledge of incidents of discrimination, harassment, retaliation, or any other
situation prohibited by this policy, should report such information to the persons listed in this general order. All reporting parties are protected from
adverse action or retaliation under the provisions of this policy and by ATSU Policy No. 10-216: Whistleblower. Good faith reports, even if erroneous,
will not result in punitive action. Deliberately false and/or malicious accusations of harassment are just as serious an offense as harassment and will
be subject to appropriate disciplinary action.
To report violations of ATSU’s nondiscrimination policies, request information, or for assistance filing a police report, contact the following persons:
Employees, members of the public, or beneficiaries should contact:
Students should contact:
Arizona Campus
Tonya Fitch
Director of Human Resources
Deputy Title IX Coordinator
5850 East Still Circle
Mesa, AZ 85206-3618
480.219.6007
[email protected]
Arizona Campus
Beth Poppre
Associate Vice President for Student Affairs
Deputy Title IX Coordinator
5850 East Still Circle
Mesa, AZ 85206-3618
480.219.6026
[email protected]
Missouri Campus
Missouri Campus
Donna Brown
Lori Haxton
Assistant Vice President of Human Resources
Vice President for Student Affairs
Deputy Title IX Coordinator
Deputy Title IX Coordinator
800 West Jefferson Street
800 West Jefferson Street
Kirksville, Missouri 63501
Kirksville, Missouri 63501
660.626.2790
660.626.2236
[email protected]
[email protected]
Alternately, discrimination complaints, reports, or questions may be directed to the ATSU Title IX Coordinator:
Joe Vincent
Title IX Coordinator
800 West Jefferson Street
Kirksville, MO 63501
660.626.2113
[email protected]
In Compliance with the Clery Act and Section 86 of DOE regulations, the university makes the following information available to all
prospective students, admitted students, and current students: Annual Security and Fire Safety Report and the Drug and Alcohol Abuse
Prevention Policy. This information can be accessed online. www.atsu.edu/security A hard copy can also be requested by contacting
Student Affairs at [email protected] or [email protected]; or at (660)626-2516 (Missouri) or (480)219-6126 (Arizona)
Annual Security and Fire Safety Report
Drug and Alcohol Abuse and Prevention Policy
Application Deadline: February 28, 2017
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A.T. Still University & Truman State University's
Summer Healthcare Career Experience (SHCE)
Parent Information/Permission Form
Please have your parent(s) or guardian(s) complete the section below:
Parent/Guardian Name
Street Address
City
State
Daytime Phone (Including Area Code)
County
Evening Phone (Including Area Code)
Email Address
Occupation
Relationship to Student:
Mother
Zip Code
Employer
Racial Category(Optional) Check as many as apply
American Indian or Alaskan Native
Highest level of education completed: Check only one
High School/GED
Father
Asian
Professional/Technical School (1-2 yrs)
Guardian
Black or African American
Some College (degree not obtained)
Step-Parent
Native Hawaiian or Other Pacific Islander
College (Associate's degree)
Other
White
College (Bachelor's degree)
Other
Graduate School
Are you Hispanic or Latino?(Optional)
No
Yes
Other
Parent/Guardian Name
Street Address
City
State
Daytime Phone (Including Area Code)
County
Evening Phone (Including Area Code)
Email Address
Occupation
Relationship to Student:
Mother
Zip Code
Employer
Racial Category(Optional) Check as many as apply
American Indian or Alaskan Native
Highest level of education completed: Check only one
High School/GED
Father
Asian
Professional/Technical School (1-2 yrs)
Guardian
Black or African American
Some College (degree not obtained)
Step-Parent
Native Hawaiian or Other Pacific Islander
College (Associate's degree)
Other
White
College (Bachelor's degree)
Other
Graduate School
Are you Hispanic or Latino?(Optional)
No
Yes
Other
I have read the application and certify that the information is accurate. I give permission for my child to apply and participate in this program. I agree
to attend the information session with my child should he/she be invited. If my child is accepted, I understand that I will receive additional
information regarding the program. If my child is accepted and participates, I agree to support him/her by attending informational sessions, and will
willingly respond as requested to surveys regarding my child and his/her progress. I understand that this information will remain confidential.
Parent Signature
Date
Application Deadline: February 28, 2017
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A.T. Still University & Truman State University's
Summer Healthcare Career Experience (SHCE)
A school representative must complete the section below.
I certify that
has a current overall GPA of
I certify that
's class rank is
of
School Representative Name
School Representative's Email Address
(on a 4 point scale).
.
Title
School Representative's Phone Number (Including Area Code)
School Representative's Signature
Date
Required Documents to Enclose:
Completed and signed Application Form
Essay questions
A current high school transcript
Parent Information/Permission Form
Please mail to:
OR
Scan and Email to:
Fax:
Amanda Clark, MA
A.T. Still University
800 W. Jefferson St.
Kirksville, MO 63501
[email protected]
(660)626-2969
If you have any questions, please call the ATSU Admissions Office at:
Phone:
(660)626-2237
Email:
[email protected]
All applicants will be notified by email of their application status by April 1, 2017.
Online complete applications will be accepted and evaluated.
Thank you for applying the the ATSU/TSU Summer Healthcare Career Experience!!
Application Deadline: February 28, 2017
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