2017 Statewide Heads Up Camp –
Helena
Program Application
Program Description
What: Heads Up Camp is a 4-day program developed by the Montana AHEC (Area Health Education Centers) and
Montana Hospital Association. The camp is hosted in partnership with Shodair Children’s Hospital and the Office of
Public Instruction. This program is designed for students to explore careers in the field of Behavioral Health, learn about
topics in mental health and to acquire tools to be advocates/peer support within their schools and communities. During
camp students will explore a variety of career paths including social work, counseling, psychology, psychiatry, and other
positions within the field. The camp will focus on key topics including career tracks, stress relief, substance abuse,
community resources, suicide prevention, and resiliency. Students are also certified in the evidence-based training –
Youth Mental Health First Aid. The course provides students with tools to empower them when assisting peers in
distress and identifies resources for proper referral.
When: July 30th – August 2nd
Where: Helena, MT - Shodair Children’s Hospital
Who: Current high school sophomores and juniors. Students must be no older than 18.
Cost: Cost to attend Heads Up Camp is $200/student. Tuition covers room & board, transportation during camp, all
activities, and student materials. Multiple scholarships are available based on need, and/or merit – See page 4 for
details.
Applications must be received by June 1st, 2017
Send applications to:
Attn: 2017 Heads Up Camp - AHEC
Montana Hospital Association
2625 Winne Avenue
Helena, MT 59601
Or.
Fax: 406-449-6571
Or.
Email: [email protected]
For questions, please contact:
Natascha Robinson – [email protected] - 406-457-8048
Shani Rich – [email protected] – 406-457-8018
2017 Heads Up Camp Application Form
PERSONAL INFORMATION **Attach additional pages as needed, include your name on each page**
1. Last name:_________________________________First:__________________________________________M. initial:________
2. Mailing address:__________________________________________________________________________________________
Town
State
Zip code
3. Home Phone: _________________________________
4. Student Cell Phone: __________________________________
5. Student E-mail: _____________________________________________________________________
*Please provide valid, legible, email addresses that will be checked regularly. This will be the method of communication from the Heads Up staff.
6. Parent E-mail: ______________________________________________________________________
7. Gender: [ ] Female [ ] Male
8. Birth date:___________________________
9. Current age:_________________________
What grade are you in currently? [ ] 10th [ ] 11th
10. T-shirt Size: _________________________
11. Please respond according to the parent(s)/guardian(s) with whom you live most of the time:
Parent or Guardian #1
Name:____________________________________________________ Email: _________________________________________
Phone: ___________________________________________________
Parent or Guardian #2 (Optional)
Name:____________________________________________________ Email: _________________________________________
Phone: ___________________________________________________
12. High school presently attending: _________________________________________ City:_________________________________
13. Name of Guidance Counselor: _________________________________________ School Phone:_______________________
14. Do you plan to attend college?
YES: [ ] 2 yrs.
[ ] 4 yrs
[ ] Other: _________________________________________________________________
NO: Other post-graduation plans: ________________________________________________________________________
15. How interested in a behavioral health career are you? (circle one)
Not at all
Somewhat
Very
16. How likely are you to pursue education in a behavioral healthcare field? (circle one)
Not at all
Somewhat
Very
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17. Please list your areas of career interest.
____________________________________________________________________
____________________________________________________________________
18. Please list any community service, volunteer, or extracurricular activities you have participated in during high school.
19. Please list any job experience while attending high school.
20. Please list any accomplishments/honors you have received while attending high school.
ESSAY QUESTIONS - PLEASE PROVIDE DETAILED ANSWERS. If needed, feel free to use additional sheets of paper.
21. What interests you about the behavioral healthcare field?
22. Why are you interested in attending Heads Up Camp and how do you feel it could contribute to your career plans?
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23. What opportunities have you had to learn about health professions? What barriers to learning about health professions have
you experienced?
24. Please describe any life experiences and/or achievements you would like to share that inspired you to apply.
Content Note
The goal of Heads Up camp is to provide an informational, inspiring, safe, and fun program for students. Due to the nature of the
content within the field of behavioral health, some topics may be upsetting for some students. Students are encouraged to step out
of any session that they may find uncomfortable. We encourage you to discuss any concerns with AHEC staff prior to camp and we
will make arrangements as needed.
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Financial Aid Information & Scholarship Application
[ ] I will pay the full tuition amount of $200 and will remit payment upon acceptance to Heads Up Camp
[ ] I have checked one or more of the boxes below and would like to be considered for a scholarship
Students who meet the following criteria may be eligible for a full or partial scholarship. Please check all that applies to you:
A. Are you a student who qualifies for free or reduced lunch (even if you do not participate in the lunch program)?
_______ Check here if you qualify for the free or reduced lunch program at your school
B. Please check one:
[
[
[
[
[
[
] Hispanic/Latino
] American Indian/Alaskan Native (Please list Tribe(s)):______________________________________________________
] Asian
] Black/African American
] Native Hawaiian/Pacific Islander
] Caucasian
C. Do you live in an underrepresented community?
_______ Check here if you live in a rural community with a population of 10,000 or less.
*Missoula, Billings, Great Falls, Butte, Bozeman, Helena and Kalispell are considered urban cities.
D. Will you be the first generation in your family to attend college?
Parent or Guardian #1 Education Level:
Parent or Guardian #2 Education Level:
(Check highest level completed)
(Check highest level completed)
[
[
[
[
[
[
[
[
]Grade School
]High School
]College
]Other
]Grade School
]High School
]College
]Other
Page 4
Heads Up: Behavioral Health Careers Camp – Recommendation Form
Please return this evaluation in a sealed envelope to the student. **Do Not Mail Separately**
APPLICANT NAME: _______________________________________ SCHOOL: _______________________________
This student has asked you to provide an assessment of his/her suitability as a participant in the 4-day Heads Up: Behavioral Health
Career summer program. The program is open to current sophomores and juniors (students who will be juniors and seniors in the
fall of 2017). 22 students will be accepted state wide.
We are interested in mature, responsible, and motivated students who have:
•
•
Previously demonstrated an interest in health careers (or could benefit from learning about such options)
Demonstrated past academic achievement or whom you feel are academically promising, but whose grades may not
currently reflect this.
Students who meet one or more of the following criteria are strongly encouraged to apply:
• Under-represented minority
• From a rural area
• Economically disadvantaged
• From a family in which neither parents are college graduates
Please evaluate the applicant in the following areas :
LOWEST
HIGHEST
LEADERSHIP SKILLS
-Problem solving, ability to see alternatives, etc.
1
2
3
4
5
MOTIVATION
-Desire to achieve academically, self-initiative
1
2
3
4
5
VERBAL SKILLS AND EXPRESSION
-Clarity and coherence
1
2
3
4
5
INTERPERSONAL CONTACT
-Openness, ability to relate effectively to others
1
2
3
4
5
RESPONSIBILITY
1
2
3
4
5
MATURITY
1
2
3
4
5
ACADEMIC ACHIEVEMENT
1
2
3
4
5
ACADEMIC POTENTIAL
1
2
3
4
5
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STUDENT’S STRENGTHS AS YOU SEE THEM:
STUDENT’S WEAKNESSES AS YOU SEE THEM:
WHY WOULD THIS STUDENT BENEFIT FROM A SUMMER PROGRAM LIKE HEADS UP?
SUMMARY EVALUATION (overall impression of student and comments which may be helpful):
Please use this sheet or attach a separate letter.
____________________________________________________________________________________________
Evaluator’s Signature, Date
____________________________________________________________________________________________
School (or other organization) Department/Position
_____________________________________________________
E-mail
____________________________
Phone
st
The deadline for the Heads Up Application is June 1 , so please return this form to the student in a sealed envelope prior to this
date. The student will return this with other application materials.
**Do Not Mail Separately**
Your time is much appreciated! Thank you!
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