EMERGENCY CONTACTS STUDENT INFROMATION

STUDENT PRINTED NAME

ADDRESS CITY ZIP

EMAIL PHONE CELL

PARENT/GUARDIAN NAME ADDRESS (IF DIFFERENT THAN ABOVE)

EMAIL PHONE CELL

IN CASE OF AN EMERGENCY, PLEASE CONTACT THE FOLLOWING: MUST LIST TWO EMERGENCY CONTACTS

CONTACT INFROMATION

EMERGENCY CONTACT NAME RELATIONSHIP

ADDRESS CITY ZIP

EMAIL PHONE CELL

EMERGENCY CONTACT NAME RELATIONSHIP

ADDRESS CITY ZIP

EMAIL PHONE CELL

EMERGENCY CONTACT NAME RELATIONSHIP

ADDRESS CITY ZIP

EMAIL PHONE CELL

“Building a Skilled, Diverse Healthcare Workforce”

STUDENT INTERNSHIP CONTRACT RULES, REGULATIONS & REQUIRED TASKS

I HAVE READ AND UNDERSTAND THE RULES, REGULATIONS AND REQUIRED TASKS. I PLAN TO ADHERE TO RULES OF UPSTATE

AHEC AND THE PRECEPTOR/VOLUNTEER SITE AND COMPLETE ALL NON-COMPROMISING ASSIGNED TASKS TO THE BEST OF MY

ABILITY.

STUDENT PRINTED NAME

STUDENT SIGNATURE

DATE

INTERNSHIP SITE INFORMATION SHEET STUDENT INFROMATION

STUDENT PRINTED NAME

EMAIL PHONE CELL

ADDRESS CITY ZIP

EDUCATION

CURRENT ACADEMIC INSTITUTION CURRENT ACADMEIC YEAR

CURRENT GRADE/ CLASSIFICATION FUTURE GRADE/CLASSIFICATION

INTERNSHIP INFROMATION

INTERNSHIP SITE NAME

ADDRESS CITY ZIP

SITE SUPERVIOSR NAME PHONE EMAIL

PLEASE DETAL THE TIMES AND DATES WITHIN THE WEEK THAT YOU WILL BE VISITING YOUR INTERNSHIP.

TIME IN TIME OUT

MONDAY

TUESDAY

WEDENSDAY

THURSDAY

FRIDAY

SATURDAY

SUNDAY

“Building a Skilled, Diverse Healthcare Workforce”

INTERNSHIP RULES & REGULATIONS PERSONAL APPEARANCE

1. Clothing is to be clean and neatly pressed. 2. Absolutely NO shorts, skorts, miniskirts, or stirrup pants! Clean tennis shoes should be worn; sandals are not

permitted – veterinarian or zoo volunteers are allowed to dress according to organization policy. 3. Name tags should be worn at all times when on duty. 4. Hair is to be clean and manageable always. Conspicuous make-up should not be worn. 5. Simple, tasteful, conservative jewelry is allowable. Jewelry that dangles can present a safety hazard and is not

allowed. Visible body piercing (with the exception of ears) is not allowed. 6. Any student volunteer reporting for duty in inappropriate attire will be sent home. If it occurs a second time,

the volunteer will be suspended from the program.

HEALTH REQUIREMENTS

1. All Student volunteers are required to complete the “two-step” TB screening procedure and any other health screening required by the volunteer site.

BEHAVIOR

1. Student volunteers are only allowed to work between 8:30 a.m. and 5:00 p.m. Monday - Friday. If the student volunteer has made special arrangement s with the health organization based on needs and availability, the schedule must be and approved by the AHEC coordinator.

2. Student volunteers should not report for work unless scheduled to do so. 3. Student volunteers are expected to be in their work area or on an errand for their assigned department while

signed in. One fifteen-minute break and a lunch period are allowed on each shift. 4. Student volunteers work solo, or in pairs only. Gathering of volunteers or family and friends is unacceptable.

Loud talking in the halls is not appropriate. Running and “horseplay” are inappropriate and can pose a safety hazard.

5. Patient privacy should be protected at all times, and all medical information will be considered strictly confidential.

6. No guns or other lethal weapons, no gum, no smoking, no drugs (including alcohol), no fragrances, no profanity – NO EXCEPTIONS.

7. Telephone calls are limited to emergency situations or calls concerning transportation. 8. No personal patient visits are allowed while on duty. Student volunteers cannot leisurely visit other volunteers

or staff at the medical center. Student volunteers cannot arrange to meet friends on the volunteer organization’s premises or anywhere during volunteer hours.

MEDIA RELEASE FORM * ASTERISKS INDICATES PARENT/LEGAL GUARDIAN’S SIGNATURE REQUIRED IF APPLICANT IS UNDER AGE 21

MEDIA

BY SIGNING BELOW I GIVE EXPLICIT PERMISSION FOR UPSTATE AHEC, SOUTH CAROLINA AHEC, AND AFFILIATE ORGANIZATIONS TO USE MY/MY CHILD’S LIKENESS OR IMAGE. USES INCLUDE, BUT ARE NOT LIMITED TO: PHOTOGRAPHY, VIDEOTAPE, ORGANIZATIONAL WEB SITE, OR PRINT MEDIA.

I ACCEPT THESE TERMS AND CONDITIONS

INITIALS** DATE

LIABILITY

I HAVE READ AND UNDERSTAND THIS FORM. I CERTIFY THAT I AM THE ABOVE NAMED STUDENT, OR THAT THE ABOVE NAMED STUDENT IS MY CHILD (OR UNDER MY LEGAL GUARDIANSHIP) AND RESIDES WITH ME IF UNDER AGE 21. I GIVE MY CONSENT TO HIM/HER/SELF TO ATTEND AND PARTICIPATE IN ACTIVITIES, FUNCTIONS AND TRIPS SPONSORED BY THE UPSTATE AHEC AND SOUTH CAROLINA AHEC. I ASSUME ALL TRANSPORTATION COSTS, SHOULD IT BE NECESSARY FOR MY/MY CHILD TO RETURN HOME DUE TO MEDICAL OR DISCIPLINARY ACTIONS.

I ACCEPT THESE TERMS AND CONDITIONS

INITIALS** DATE

I DO HEREBY RELEASE, FOREVER DISCHARGE, AND AGREE TO HOLD HARMLESS UPSTATE AHEC, SOUTH CAROLINA AHEC, ITS STAFF, FACULTY, CHAPERONES AND VOLUNTEERS THEREOF FROM ANY AND ALL LIABILITY, CLAIMS OR DEMANDS FOR PERSONAL INJURY, SICKNESS OR DEATH, AS WELL AS PROPERTY DAMAGE AND EXPENSES OF ANY NATURES WHATSOEVER WHICH MAY BE INCURRED WHILE PARTICIPATING IN ANY ACTIVITY OR TRIP. I ASSUME ALL RISK OF PERSONAL INJURY, SICKNESS, DEATH, DAMAGE AND EXPENSE AS A RESULT OF PARTICIPATION IN RECREATION AND WORK ACTIVITIES INVOLVED THEREIN BY MY CHILD. I UNDERSTAND BY MY SIGNATURE THAT THIS FORM IS BOTH A BINDING MEDICAL AND LIABILITY RELEASE.

STUDENT PRINTED NAME DATE

PARENT/ LEGAL GUARDIAN SIGNATURE ** DATE IF UNDER AGE 21

MEDICAL RELEASE FORM STUDENT INFROMATION

STUDENT PRINTED NAME

- - DATE OF BIRTH SOCIAL SECURITY NUMBER (MM/DD/YYY) (XXX-XX-XXXX)

HEALTH HISTORY

PLEASE LIST ANY ALLERGIES STUDENT HAS:

PLEASE LIST THE NAME, DOSAGE, AND SCHEUDLE OF MEDICATIONS THAT MUST BE TAKEN:

DATE OF LAST TENTUS SHOT

OTHER CONDITIONS:

HEART CONDITION �

DIABETES �

ASTHMA �

FREQUENT STOMACH ACHE �

EPILEPSY �

GLASSES / CONTACTS �

HAY FEVER �

HEARING AID �

FREQUENT COLDS �

PHYSICAL IMPAIRMENT �

PREGNANCY �

ACTIVITY RESTRICTION �

IF YOU CHECK ANY CONDITIONS PRESENTED ON THE BOX TO THE RIGHT, PLEASE GIVE DETAILS: (TREATMENT, MEDICATION, IN CASE OF EMERGENCY)

INSURANCE

* ASTERISKS INDICATES PARENT/LEGAL GUARDIAN’S SIGNATURE REQUIRED IF APPLICANT IS UNDER AGE 21

THE INSURANCE PROVIDED BY THE SOUTH CAROLINA AHEC/ UPSTATE AHEC IS ONLY SECONDARY INSURANCE. IF YOU HAVE MEDICAL INSURANCE, YOUR CARRIER WILL BE BILLED FOR MEDICAL CHARGES IN THE CASE OF ILLNESS OR INJURY. WHILE I/MY CHILD AM/IS PARTICIPATING IN AN AHEC-RELATED ACTIVITY OR TRIP, I ASSUME ALL RESPONSIBILITY OF ALL MEDICAL BILLS. INSURANCE CARRIER POLICY NUMBER

POLICY HOLDER NAME

I ACCEPT THESE TERMS AND CONDITIONS

INITIALS** DATE

IN THE EVENT I AM UNABLE TO PROVIDE INFORMATION DURING AN EMERGENCY, I HEREBY GIVE PERMISSION TO THE MEDICAL PROFESSIONAL SELECTED BY UPSTATE AHEC AND SOUTH CAROLINA AHEC LEADERSHIP TO SECURE PROPER TREATMENT, INCLUDING BUT NOT LIMITED TO: MEDICAL EVALUATION, MEDICAL INJECTION, ANESTHESIA, SURGERY, AND HOSPITALIZATION FOR ME/MY CHILD AS DEEMED NECESSARY.

I ACCEPT THESE TERMS AND CONDITIONS

INITIALS** DATE

ORIENTATION & WORKFORCE TRAINING UPSTATE AHEC SUMMER ENRICHMENT PROGRAM

“Excellence in healthcare though education”

WELCOME

PURPOSE

ORIENTATION

SITES

RULES, REGULATION, DRESS CODE

HIPAA TRAINING

SITE PROCEDURES & ORIENTATIONS

SUMMER COURSE & ACTIVITES

COLLEGE TOUR

CNA

CPR TRAINING

DISASTER TRAINING: INTRODUCTORY CERT PROGRAM

INDUSTRY TOUR: CARDIOVASCULAR CENTER

QPR SUICIDE PREVENTION CERTIFICATION

ENRICMENT PROGRAM

THE DIFFERENCE: INTERNSHIP, SHADOWING, VOLUNTEER

WIX

ONLINE PORTFOLIO

RESUME BUILDING

WHAT MAKES A RESUME STRONG?

ACTIVITY

BUILDING YOUR SKILLS

MENTAL HEALTH CERTIFICATION TRAINING

MRS. LAMPART

SUMMER ENRICHMENT PROGRAM HEALTH CAREERS PROGRAM

ORIENTATION & WORKFORCE TRAINING SUMMER INTERNSHIP JUNE 13, 2017 AT 9:00AM-1:00PM JUNE 26, 2017-JULY 25, 2017

ELIGIBILITY:

Applicants are required to:

• Be in good academic standing.

• Demonstrate a sincere interest in a specified health care field.

• Understand that ALL internship sites will be located within counties included in the specified AHEC’s region With an exception to Upstate college students (Upstate AHEC counties included in the region are listed at

www.upstateahec.org).

• Understand that the application process for the Upstate AHEC Summer Enrichment Program is competitive. Submission of this application DOES NOT guarantee acceptance into the program or enrichment opportunities.

• Understand that additional forms and fees are required if accepted to attend the Summer Enrichment Program.

• Inform parents/guardians of possible acceptance.

• Provide transportation to internship placement site and/or the drop-off and pick-up locations for the Summer Enrichment Program if accepted.

DIRECTIONS:

Applications must be TYPED OR PRINTED IN INK or completed online at www.upstateahec.org (preferred method).

A non-refundable, $25 application fee must accompany the application.

DEADLINE: ALL applications must be received by JUNE 7, 2017

Completed applications must include:

A COPY OF MOST RECENT REPORT CARD PAYMENT TWO LETTERS OF RECOMMENDATION from a professional and any other adult who is familiar with your

academic work, community service work, or character, and who is NOT a family member, using the enclosed recommendation sheets or online at www.upstateahec.org – preferred method). ** This is only for students who are not currently participating in the Health Careers Academy during the school year

ALL SECTIONS OF THE APPLICATION MUST BE COMPLETED.

APPLICATION DEADLINE: JUNE7, 2017

Submit Application along with Check/Money Order in the amount of $25 to: Upstate AHEC 104 South Venture Dr. Greenville, SC 29615

SUMMER ENRICHMENT PROGRAM APPLICATION HEALTH CAREERS PROGRAM

GENERAL INFORMATION:

ARE YOU CONSIDERING TAKING A SUMMER SCHOOL COURSE?

IF APPLYING FOR THE SUMMER ENRICHMENT PROGRAM:

• I will be able to provide daily transportation to/from sites: • INDICATE YOUR PREFERENCE OF COUNTY: CITY:

STUDENTS SELECTED TO ATTEND THE 2017 SUMMER ENRICHMENT PRORGAM WILL RECEIVE T-SHIRTS.

PLEASE INDICATE T-SHIRT SIZE □ XXL □ XL □ L □ M □ S

IF YOU ARE A COLLEGE STUDENT, ARE YOU WILLING TO SERVE AS A ROLE MODEL FOR A HIGH SCHOOL STUDENT DURING THE SUMMER ENRICHMENT PROGRAM AND FOR THE NEXT ACADEMIC SCHOOL YEAR?

DOES SC AHEC AND UPSTATE AHEC HAVE PERMISSION TO USE PHOTOGRAPHS TAKEN OF YOU FOR ITS WEBSITE, BROCHURES, OR OTHER PUBLICATIONS?

DEMOGRAPHIC INFORMATION:

FULL NAME (FIRST, MIDDLE, LAST)

ADDRESS CITY ZIP

AGE DATE OF BIRTH (MM/DD/YYYY) PLACE OF BIRTH (CITY/COUNTY & STATE)

GENDER SOCIAL SECURITY (XXX-XX-XXXX)

EMAIL PHONE (XXX-XXX-XXXX) CELL (XXX-XXX-XXXX)

RACE/ ETHNICITY:

Yes � No �

Yes � No �

□ LATINO □ CAUCASIAN □ AMERICAN INDIAN □ AMERICAN INDIAN □ ASIAN

□ HISPANIC □ PACIFIC ISLANDER □ NATIVE HAWAIIAN □ AFRICAN AMERICAN □ ALASKA NATIVE

□ NOT LISTED:

Yes � No � Possibly �

Yes � No � Possibly �

FAMILY:

NUMBER OF IMMEDIATE FAMILY MEMBERS CURRENTLY LIVING IN THE HOUSEHOLD (INCLUDING SELF).

_____BROTHERS _____SISTERS _____PARENTS/GUARDIANS _____TOTAL (INCLUDE SELF)

ACADEMIC INFORMATION:

CURRENT ACADEMIC INSITITUTION

ADDRESS CITY STATE ZIP

CURRENT ACADEMIC CLASSIFICATION LAST DAY OF CLASS/ GRADUATION (HIGH SCHOOL: 9, 10, 11, 12 OR COLLEGE: FRESHMA, SOPHOMORE, JUNIOR, SENIOR)

IF HIGH SCHOOL: GUIDANCE COUNSELOR NAME EMAIL

IF COLLEGE: MAJOR MINOR/ CONCENTRATION

LIST ALL EDUCATIONAL INSTITUTIONS (MOST RECENT FIRST) YOU HAVE ATTENDED:

NAME OF SCHOOL LOCATION GRADUATION DATE DEGREE EARNED

___________________________ _____________________________ ____________ ___________ ___________________________ _____________________________ ____________ ___________ ___________________________ _____________________________ ____________ ___________ LIST ANY HONORS/DISTINCTIONS RECEIVED FOR SCHOLASTIC ACHIEVEMENTS:

_____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________

LIST ANY EXTRACURRICULAR AND/OR COMMUNITY SERVICE ACTIVITIES (EXCLUDING JOBS HELD DURING YOUR HIGH SCHOOL/COLLEGE YEARS). PLEASE INCLUDE ANY AHEC ACTIVITIES.

_____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________

WORK EXPERIENCE:

LIST ANY JOBS (INCLUDING SUMMER EMPLOYMENT) YOU HAVE HELD IN THE PAST TWO YEARS.

POSITION EMPLOYER DATES OF EMPLOYMENT HRS./WEEK

_________________________ ________________________ __________ to ___________ __________ _________________________ ________________________ __________ to ___________ __________ _________________________ ________________________ __________ to ___________ __________

ESSAY:

USING A SEPARATE SHEET OF PAPER, TYPE A BRIEF ESSAY ANSWERING THE FOLLOWING QUESTIONS:

WHICH HEALTH CAREER ARE YOU MOST INTERESTED IN AND WHY?

HOW DO YOU THINK THAT PARTICIPATION IN THE UPSTATE AHEC SUMMER PROGRAM WILL HELP YOU ACHIEVE YOUR GOAL OF OBTAINING A HEALTH CAREER?

YOU MAY ATTACH RÈSUMÈ &/OR COVER LETTERS TO THIS APPLICATION.

Upstate Area Health Education Center

104 South Venture Drive, Greenville SC 29605

864-349-1160

hcpstudent@upstateahec.org

NITA DONALD

HEALTH CAREERS PROGRAMS DIRECTOR

TABLE OF DOCUMENTS SUMMER ENRICHMENT PROGRAM

PROGRAM APPLICATION

INTERNSHIP SITE INFORMATION

INTERNSHIP RULES & REGULATIONS

STUDENT INTERNSHIP CONTRACT

MEDICAL RELEASE FORM

MEDIA RELEASE FORM

EMERGENCY CONTACT SHEET

GERONTOLOGY (CNA) SUMMER COURSE

PROGRAM APPLICATION

SUMMER COURSE SYLLABUS

REQUIREMENT CHECK

DOCUMENTS REQUIRED BY YOU IMMUNIZATION FORM