“HEALERS” Check list: - UAMS Medical Center

UAMS MEDICAL CENTER“HEALERS”DEADLINE TO APPLY: WEDNESDAY, MARCH 20 TH 2013LAST NAME:_______________________________________________ FIRST NAME: __________________________________M:________ADDRESS: __________________________________________________ CITY: _________________________ ZIP:______________HOME PHONE: ______________________________________ CELL PHONE: ___________________________________________E-MAIL (REQUIRED):________________________________________________________________________________________GENDER: __________ DATE OF BIRTH: ____/_____/_________ T-SHIRT SIZE: ____________________SOC. SEC. NUMBER: _____________________________NAME OF HIGH SCHOOL: ______________________________________________ YEAR OF GRADUATION: __________________PARENT/GUARDIAN’S NAME(S):_____________________________________________________________________________PARENT/GUARDIAN’S ADDRESS (IF DIFFERENT FROM ABOVE):______________________________________________CITY: _________________________________ ZIP: _______________ PHONE: _______________________________________PERSON TO CONTACT IN CASE OF EMERGENCY (IF DIFFERENT FROM ABOVE):NAME/RELATIONSHIP: ________________________________________________________ PHONE: ______________________ALT. PHONE: _________________

QUESTIONS FOR APPLICANTPLEASE USE THE SPACE PROVIDED TO ANSWER THE FOLLOWING QUESTIONS. FEEL FREE TO ATTACH ADDITIONALPAPER, IF NECESSARY. PLEASE TYPE OR WRITE NEATLY.1) WHY ARE YOU INTERESTED IN VOLUNTEERING AT UAMS?2) WHERE DO YOU HOPE TO BE IN THE NEXT 5 YEARS (EDUCATION, CAREER, FAMILY, ETC)

3) WHAT SIGNIFICANT SCHOOL OR NON-SCHOOL ACHIEVEMENTS HAVE YOU ACCOMPLISHED? PLEASEDESCRIBE JOBS OR DUTIES YOU HAVE HELD IN THE COMMUNITY, AT SCHOOL, OR AT HOME THATDEMONSTRATE YOUR DEPENDABILITY, COMMITMENT AND RESPONSIBILITY.4) TELL US ABOUT YOUR SUMMER PLANS. ANYTHING THAT WOULD INTERFERE WITH PARTICIPATION INTHE PROGRM SUCH AS VACATIONS, CAMPS, OR OTHER COMMITMENTS?

ACCEPTANCE STATEMENTALL EXPENSES FOR THE “HEALERS” WILL BE PAID BY THE UAMS MEDICAL CENTER AUXILIARY. YOU MUST AGREE TOATTEND THE FULL LENGTH OF THE PROGRAM (2 WEEKS). PLEASE NOTE THAT THIS IS A DAYTIME PROGRAM AND THATTRANSPORTATION TO AND FROM EACH DAILY SESSION IS YOUR RESPONSIBILITY.SIGNED: ____________________________________________________________DATE: _____________________________(STUDENT)ACCEPTANCE/PERMISSION STATEMENTI UNDERSTAND THAT IF MY CHILD IS ACCEPTED, THAT ALL EXPENSES FOR THE “HEALERS” WILL BE PAID BY THE UAMSMEDICAL CENTER AUXILIARY. I UNDERSTAND THAT MY CHILD, WITH SIGNATURE ABOVE, HAS AGREED TO ATTENDTHE FULL LENGTH OF THE PROGRAM (2 WEEKS) AND THAT I WILL BE RESPONSIBLE FOR HIS/HER DAILYTRANSPORTATION FOR THE DURATION OF THE PROGRAM.I HEREBY GRANT PERMISSION FOR MY CHILD TO APPLY TO THIS PROGRAM AND FOR A SELECTED REFERENCE TOREPORT MY CHILD’S ACHIEVEMENT AND GRADES.SIGNED: ____________________________________________________________ DATE: _____________________________(PARENT/GUARDIAN)PLEASE RETURN COMPLETED FORM TO:JENNIFER HUIE, VOLUNTEER COORDINATORUAMS MEDICAL CENTER4301 W. MARKHAM, #527LITTLE ROCK, AR 72205501.686.5657 (PHONE) 501.296.1072 (FAX)APPLICATIONS ARE DUE WEDNESDAY, MARCH 20 TH 2013

UAMS MEDICAL CENTERSUMMER TEEN VOLUNTEER PROGRAM REFERENCE FORMDEADLINE TO SUBMIT: WEDNESDAY, MARCH 20 TH 2013STUDENT NAME :_______________________________________________________________________________REFERENCE NAME :______________________________________________________________________________REFERENCE TITLE: ___________________________________ RELATIONSHIP TO STUDENT: __________________________REFERENCE ADDRESS: _______________________________________ CITY: _____________________ ZIP: ________________PLEASE ANSWER THE FOLLOWING QUESTIONS CANDIDLY AND THOROUGHLY. ATTACH ADDITIONAL SHEETS IFNECESSARY. ALL INFORMATION PROVIDED WILL BE KEPT CONFIDENTIAL.1. HOW WOULD YOU DESCRIBE THIS STUDENT’S LEVEL OF ACADEMIC ACHIEVEMENT?

2. HOW WOULD YOU DESCRIBE THIS STUDENT’S WORK ETHIC AND DEDICATION TO ACHIEVING HIS/HER GOALS?3. HOW WOULD YOU DESCRIBE THIS INDIVIDUAL’S INTERACTION WITH OTHERS?4. WHAT DO YOU THINK MAKES THIS STUDENT ESPECIALLY DESERVING OF THIS OPPORTUNITY?

5. IN WHAT AREA(S) DO YOU THINK THIS STUDENT NEEDS TO MAKE THE MOST IMPROVEMENT IN ORDER TO ACHIEVEHIS/HER GOALS?REFERENCE AGREEMENTI UNDERSTAND THAT INFORMATION PROVIDED ON THIS SHEET MAY BE USED BY THE SELECTION COMMITTEE INORDER TO DETERMINE A STUDENT’S CANDIDACY IN “HEALERS” PROGRAM, BUT THAT NO INFORMATION WILL BESHARED AND ALL INFORMATION WILL REMAIN CONFIDENTIAL.SIGNED: _______________________________________________________________ DATE: ____________________________(REFERENCE)PLEASE RETURN COMPLETED FORM TO:JENNIFER HUIE, VOLUNTEER COORDINATORUAMS MEDICAL CENTER4301 W. MARKHAM, #527LITTLE ROCK, AR 72205501.686.5657 (PHONE) 501.296.1072 (FAX)JLHUIE@UAMS.EDUALL APPLICATIONS AND RELATED INFORMATION ARE DUE BY WEDNESDAY, MARCH 20 TH 2013