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2019 Summer Diversity Healthcare Camp Application
Please complete the application in its entirety for consideration as a participant in our camp held June 17-21, 2019.
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* Indicates required question
Applicant's First and Last Name
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Your answer
Applicant's Street Address
*
Your answer
City, State and Zip Code
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Your answer
Contact Phone Number
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Your answer
Cell Phone Number (if different)
Your answer
Applicant's Email Address
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Your answer
Parent/guardian Email Address
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Your answer
Race/ethnicity
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African-American/Black
Asian/Pacific Islander
Caucasian/White
Hispanic/Latino
Native-American/American Indian
Other:
Gender
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Female
Male
Name of High School
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Your answer
City and County of High School
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Your answer
Expected High School Graduation Year
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Your answer
Current cumulative GPA (minimum 3.0)
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Your answer
T-shirt size
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XS
S
M
L
XL
XXL
Other:
Application Essay: Please state why you are interested in participating in the SIUE Healthcare Diversity Summer Camp.
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Your answer
Applicant's Signature (please type your name acknowledging that all information provided is accurate and you are able to participate if selected)
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Your answer
Legal Guardian's Signature (please type your name acknowledging that all information provided is accurate and you give permission for your child to participate in our onsite camp if selected)
*
Your answer
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