Southeast KY AHEC Summer Scrub C

Southeast KY AHEC Summer Scrub Camp Application

General Information:

____________________________________ ___________________________________
Last Name First Name

____________________________ ____________________ ____________ _________
Address City State Zip

______________________________ (_____)______-________ (_____)______-_________
Parent/Guardian Home Phone Work/Cell Phone

School Information:

____________________________________ ___________________ ______________
Name of School Current Grade Level GPA

Please list two references who know you as a student:

_____________________________ _________________________ (______)______-_________
Name Title Phone

Please include a one page essay describing your interest in health careers and why you wish to become a health care professional.

Please select which camp you are applying for:

These camps are offered to those students that will be in the 7^th THRU 12^th grade as of the 2009/2010 school year:

This camp is offered to those students that will be in the 7^th OR 8^th grade as of the 2009/2010 school year:
Perry County (7/6/09 thru 7/10/09)

This camp is offered to those students that will be in the 8^th grade as of the 2009/2010 school year:
Letcher County (6/16/09 thru 6/18/09)

Southeast KY AHEC
Attn: Summer Scrubs Camp
180 Taylor Ridge Road, Suite 101
Hazard, KY 41701

For more information please call the Southeast KY AHEC office @ (606)487-0135.